Introductory Medical Surgical Nursing 11th Edition by Barbara K. Timby – Smith – Test Bank





Introductory Medical Surgical Nursing 11th Edition by Barbara K. Tim by – Test Bank


 Sample  Questions



1. Which of the following roles of a nurse is an example of legitimate power?
A) Director of nursing
B) Team leader making assignments
C) Head nurse scheduling vacations
D) Shift supervisor
Ans: A
Legitimate power is power by virtue of the management position. Director of nursing is an example of legitimate power. Team leader making assignments is an example of reward power. Head nurse scheduling vacations is an example of coercive power. Shift supervisor is an example of referent power.



2. Which of the following is the perceived advantage of autocratic leadership styles?
A) Staff members are invested in management’s goals.
B) Decisions are made without any input from staff.
C) Communication is limited to memos.
D) Decisions may not occur on time.
Ans: B
In autocratic leadership style, the lines of authority and policies are clear, and communication is directive and flows downward. In addition, decisions are made quickly, and staff members are not invested in management’s goals.



3. A licensed practical nurse (LPN) has delegated a task to unlicensed assistive personnel (UAP). Who is accountable for evaluating the results of the tasks?
A) Physician
B) Shift supervisor
Ans: D
An LPN or licensed vocational nurse (LVN) who delegates tasks to a UAP is accountable for evaluating the results of the tasks. The UAP is responsible for performing the actual task. The physician or shift supervisor is not accountable for evaluating the results of the tasks.



4. According to Ellis and Hartley (2011), which type of leadership involves the least amount of structure and control?
A) Autocratic
B) Laissez-faire
C) Democratic
D) Multicratic
Ans: B
Laissez-faire leadership involves the least structure and control. Autocratic leadership entails strong control by the manager over the work group. Democratic leadership involves more participation in decision making by the work group. Multicratic leadership allows a leader to determine which approach is best for a particular circumstance.



5. A nurse manager who denies vacation time to an employee who failed to meet expectations is exhibiting what type of power?
A) Legitimate
B) Coercive
C) Reward
D) Referent
Ans: B
Coercive power is the ability to threaten or punish someone who fails to meet expectations. Legitimate power is obtained through a designated position. Reward power occurs when a person attains power through the ability to grant favors or rewards. Referent power is the power a person has because of his or her association with other who are powerful.



6. A nurse manager typically exhibits which type of power when using education and work experience?
A) Referent
B) Legitimate
C) Coercive
D) Expert
Ans: D
Expert power results from knowledge, expertise, or experience in a particular area. Referent power concerns the power a person has because of his or her association with other who are powerful. Legitimate power is obtained through a designated position. Coercive power is the ability to threaten or punish someone who fails to meet expectations.



7. Which of the following is an advantage of democratic leadership?
A) Tasks are accomplished without staff input.
B) Leaders see themselves as coworkers.
C) Quick decision making occurs.
D) Managers provide support and freedom for employees.
Ans: B
Democratic leadership involves more participation in decision making by the work group. Leaders with this style often see themselves as coworkers. Autocratic leadership allows little input from staff for decisions. In laissez-faire leadership, the manager leaves the work group to set goals, make decisions, and take responsibility for their own management.



8. Which of the following would not be considered one of the five rights of delegation?
A) Educational level
B) Task
C) Circumstances
D) Person
Ans: A
The NCSBN (1997) identified the five rights of delegation: right task, right circumstances, right person, right direction/communication, and right supervision/evaluation.



9. Which of the following would be considered an indirect activity that may be delegated to unlicensed assistive personnel?
A) Delivering meal trays
B) Obtaining vital signs
C) Ambulation
D) Specimen collection
Ans: A
Indirect activities are focused on environmental tasks, such as cleaning equipment, emptying trash or soiled linen receptacles, and delivering meal trays. Direct activities are those that help clients meet basic needs, including vital signs, weights, specimen collection, and ambulation.



10. The leader is making all the decisions for the group. Which type of leadership is being exhibited?
A) Autocratic
B) Democratic
C) Laissez-faire
D) Multicratic
Ans: A
Autocratic leadership entails strong control by the manager over the work group. Democratic leadership involves more participation in decision making by the work group. Laissez-faire leadership involves the least structure and control. Multicratic leadership allows a leader to determine which approach is best for a particular circumstance.



11. The nurse at a long-term care facility is receiving an admission to a skilled medical unit with a full census. Which nursing situation is the best example of a nurse demonstrating appropriate management skills in the care of the client?
A) The nurse is arranging the room to best accommodate the client’s medical equipment.
B) The nurse is obtaining the needed paperwork to begin the admission process.
C) The nurse is delegating patient orientation to the room while obtaining contact information from the family.
D) The nurse is obtaining a urinary collection hat for the toilet.
Ans: C
Management of clients, especially on a busy unit, is best accomplished by delegation of appropriate tasks. A manager must use resources in an efficient and effective manner to accomplish a goal. The manager sees the big picture and determines appropriate actions.



12. Which of the following statements best demonstrates a combination of leadership and management skills when teaching a client with uncontrolled diabetes?
A) “While you have agreed to check your blood sugar every morning, it is also important to recognize the overall effect on your body system.”
B) “Once you have the lancet in the device, hold it against the finger and press the button.” You are doing a good job.
C) “Because Thanksgiving is next week, evaluate the amount of simple sugars in the desserts and eat those in moderation.”
D) “I will notify your physician of your blood glucose reading and request a referral for a dietician to improve your knowledge of calorie controlled diets.”
Ans: A
In many ways, leadership and management skills are interrelated. Option A uses management skills of instructing on obtaining blood sugars every morning and leadership skills of looking at the overall picture of the disease process within the system. Option B provides instruction on a procedure. Option C instructs on managing dietary habits. Option D does not include using management and leadership in teaching a client.



13. The nurse is caring for pediatric clients on an oncology unit. The unit is experiencing a renovation, and the nurse manager is requesting suggestions for placement of the nurse’s station with the goal of close pediatric client access. Which type of leadership style is the nurse manager employing?
A) Political leadership style
B) Democratic leadership style
C) Laissez-faire leadership style
D) Authoritarian leadership style
Ans: B
When a manager uses the democratic leadership style, the manager welcomes participation in decision making with a goal of consensus and teamwork. Option A and D are not leadership styles. Option C is a leadership style that involves little structure and guidance.



14. During which client–nurse interaction would the nurse most appropriately use the autocratic leadership style?
A) The nurse is assisting the client to the bathroom when wound dehiscence occurs.
B) The nurse is presenting meal options to a resistant diabetic client.
C) The nurse is instructing on how to obtain blood glucose readings.
D) The nurse is preparing discharge instructions per physician’s order.
Ans: A
During an emergency, such as when a wound dehiscence occurs, an autocratic leadership style with one person in tight control of the situation is best. At this time, the focus is on accomplishing the tasks of patient safety, wound care, and physician notification. All of the other interactions would best be managed with a therapeutic nurse patient interaction.



15. A mother of a 10-year-old newly diagnosed diabetic client expresses concern that her child will not follow through with the diabetic regimen. The nurse suggests developing a calendar of daily requirements with a weekly prize for completing. The mother is exerting which type of power to obtain the desired result?
A) Coercive power
B) Expert power
C) Parental power
D) Reward power
Ans: D
Reward power is using rewards and favors to obtain a particular action. In this case, the mother rewards the child when the child completes the prescribed diabetic regimen. Coercive power is used when using a threat or punishment to meet expectations. Expert power results from the respected knowledge in a particular situation. Parental power many times falls under expert power.



16. The manager of the surgical unit is presenting the benefits of a new computer documentation system on reducing the nurse’s time documenting, thus increasing the time to care for clients at the bedside. Increasing nurse excitement in the changes within the system is a form of which type of power?
A) Referent power
B) Motivational power
C) Legitimate power
D) Authoritarian power
Ans: B
Motivational power refers to the ability to create enthusiasm for a collaborative project or achievement of a common goal. Referent power relates to being in or associating with someone who is in the position of power. Legitimate power is afforded to the management position but is not the best answer for this question scenario. Option D relates to leadership styles.



17. The LPN is caring for a full nursing assignment and delegates specific duties to the certified nursing assistant (CNA). Which nursing action is best to assess the competency of the CNA to complete the assignment?
A) Ask the client if the assignments were completed
B) View the paperwork related to the assignments for completion
C) Ask the CNA exactly how the assignments were completed
D) Observe the CNA during completion of the assignments
Ans: D
Observing the CNA, especially during the first time that the CNA is independent, is the best way to ensure the knowledge and competency of the CNA (a component of supervision). If the CNA performs the assignment correctly, the task can be routinely delegated with usual follow-up. Asking clients, viewing paperwork, and asking the CNA provides information on the task but is not the best choice for assessing.



18. The LPN is assigning clients on a rehabilitation unit. Which of the following nursing actions should the LPN complete prior to assigning any delegated task?
A) Complete nursing report
B) Review physician notes
C) Assess the clients
D) Obtain feedback from the CNA
Ans: C
Assessing the client prior to delegation assures the right person, task, and circumstance. The licensed nurse should assess the appropriateness of assignment to meet the skills of the person being delegated to. Completing nursing report provides information about the client, which the assessment phase confirms. Reviewing physician notes provides updated information regarding medical orders. Obtaining feedback on the assignment from CNA provides information on skill level.



19. The registered nurse (RN) delegates management of the client vital signs to the LPN while the client is receiving blood products. Which of the following RN actions is essential in completing the “right circumstance” right of delegation?
A) The RN initiates the transfusion and remains with the client during initial vital signs.
B) The RN supervises the LPN obtaining vital signs and discusses signs of a transfusion reaction.
C) The RN obtains the LPN scope of practice and determines the ability to manage client.
D) The RN discusses the specific tasks to delegate and asks for any questions.
Ans: A
To complete the “right circumstance” right, the RN must determine that the client is not having any transfusion reaction and that the client’s vitals are stable. Option B and C represents “right tasks” because the RN validates the scope of practice and supervises the competent completion of tasks. Option D represents right communication.



20. Staff is assembling for shift assignments. Which of the following nursing actions identifies the manager’s responsibility on the clinical unit?
A) The manager assesses the clients on the clinical unit and updates the physician.
B) The manager assures that adequate care is given by the staff and assesses the flow of activities on the clinical unit.
C) The manager removes the physician orders from the chart and notes completion.
D) The manager attends facility meetings and plans the goals of the healthcare facility.
Ans: B, D
The key feature of the manager’s position is the individual responsibility and accountability for the accomplishment of tasks on the clinical unit. Option B accounts for the care of the clients and flow of the clinical unit. Options A and C are task oriented, and, although the manager may assist staff, it is not the focus of the manager’s responsibility. Option D identifies manager (attending meetings) and leadership (goals of the facility) duties.



21. The LPN on the clinical unit is discussing client medication administration. The medication nurse states, “I crushed the medication because the nurse on the prior shift told me to do it.” This statement indicates a lack of which?
A) Responsibility
B) Management
C) Accountability
D) Leadership
Ans: C
Accountability means being answerable for one’s actions. Following another’s actions and using that as a rationale is not being accountable for the action taken. Responsibility is the duty or assignment to a specific task. Management entails assigning functions to meet particular objectives. Leadership provides guidance to achieve common goals.



22. The nurse is planning care for the day for a client with multiple diagnoses. Which of the following criteria should the nurse consider first when setting priorities for the care of the client?
A) Consider the priority of maintaining vital signs.
B) Consider the priority of symptom management.
C) Consider the priority of management of pain.
D) Consider the priority of preventing spread of disease.
Ans: A
All options are a priority when providing care to a client. When prioritizing, vital signs provide data on maintaining life and are considered first. All other options come after.



23. Which nursing management duties would the LPN identify as the primary goal of directing nursing care in the role of the team leader on a nursing unit?
A) To maintain the efficient flow of client care on the nursing unit
B) To ensure the personal care for all residents is completed
C) To assess vital signs on a client with changing hemodynamic status
D) To coordinate physician orders between the physician and nursing staff
Ans: A
The key words are “primary goal,” which is broad in nature. The best choice is to maintain the efficient flow of the nursing unit. Individual staff also has the responsibility to complete the nursing task of personal care and vital sign assessment. Coordinating physician orders is a combined duty between the physician and nursing staff and falls under the goal of maintaining efficient flow of client care.



24. A nurse is caring for clients on a surgical unit. Which nursing actions positively impact the goal of healthcare cost containment? Select all that apply.
A) Completing a nursing assessment and setting up a breakfast tray in an isolation client’s room
B) Teaching and encouraging the use of an incentive spirometer
C) Delegating the ambulation of a client three times daily in the hall
D) Completing client wound dressing change prior to physician rounds
E) Checking the completion of foley catheter care with the nursing assistant
F) Initiating a turning protocol for a bedbound client
Ans: A, B, C, E, F
Cost-consciousness measures include prudent use of expensive supplies, careful monitoring of clients to reduce potential complications and lengths of stay, and reduction of waste of limited resources. Options A, B, C, E, and F are examples of these.



25. A nurse is caring for a client with stage IV colon cancer and multiple-stage two wounds on the coccyx area. The client confides feeling very weak and wanting to discontinue further aggressive treatment. Which nursing action best demonstrates the nurse in the role of the patient advocate?
A) The nurse relays the message to the physician and requests an antidepressant.
B) The nurse asks the client how might his or her family feel with this decision.
C) The nurse sits with the client and suggests that the client reconsider.
D) The nurse offers to be present to support the client at a family meeting.
Ans: D
Advocacy meaning promoting the cause of another person. The nurse functions as a patient advocate by supporting the client and the client’s decisions. Offering to support the client as the client expresses healthcare decisions is the best example of a client advocate. Relaying the message to the physician and asking for an antidepressant does not demonstrate supporting the client. Opening conversation related to family response is appropriate for discussion but is not the best choice to support the client. The nurse would not ask the client to reconsider because this is a block to communication.



26. The nurse manager is discussing financial penalties for readmissions to the hospital. Which nursing action, when caring for a client, is most helpful in decreasing hospital readmission?
A) Emphasize client teaching
B) Fully explain discharge instructions
C) Sanitize hands upon entering a client room
D) Disinfect the client environment at discharge
Ans: C
All options help to reduce the potential for readmission but the key words are “most helpful”. Handwashing is the best way to reduce hospital acquired infections, which could lead to readmissions. Handwashing also maintains standards of care. Client education during hospitalization and with discharge instructions empowers the client in care of themselves. Disinfecting the client’s room reduces cross contamination.



27. The LPN is supervising the nursing unit staff when a nonlethal breach in client standards of care occurs. Which situation demonstrates the limitations of supervising client care in the role of the LPN?
A) The LPN supervisor is unable to write the incident report outlining the breach in care standard.
B) The LPN supervisor reports the breach in care standard to the RN only.
C) The LPN supervisor oversees the staff but has no disciplinary responsibility.
D) The LPN supervisor is responsible for personal care and not all nursing functions.
Ans: C
The role of the LPN supervisor does not include hiring/firing or disciplinary actions of employees. When a breach in the standards of care occurs, the LPN is responsible for documenting the event and reporting the event to the proper individuals, such as RN supervisor, administrator in charge, physician, family representative, etc. The supervisor oversees client care.



28. The LPN supervisor is assigning LPNs to clients on a skilled nursing unit at a long term care facility. In which situation would the LPN reduce the assignment due to client acuity?
A) A client who desaturates with minimal exertion
B) A client with dementia who is combative during medication administration
C) A client who needs to be ambulated in the hall with the assistance of two for restorative therapy
D) A client requires several intravenous antibiotics to treat a septic infection
Ans: A
Acuity refers to the severity of the illness and the potential rapid change in the client. A client that desaturates with minimal exertion is at risk for respiratory compromise and respiratory arrest. Careful and repeated nursing assessment is needed limiting the time for other client interactions. Dementia is a chronic condition making daily activities such as medication administration challenging. A restorative care client focuses on improving activities of daily living. A client with multiple intravenous antibiotics should improve as treatment progresses.



29. A nurse in the physician’s office must multitask assignments according to client needs. Arrange the clients in order of which should be assessed/assisted from first to last?
A) A client in an examining room on an ill office call who reports flulike symptoms
B) A client in the office reception area who appears unannounced due to chest heaviness
C) A client calling on the phone who is inquiring about doubling the morning dose of medication because of forgetting the last day’s dose
D) A client who needs to be called by the nurse to advice of a medication dosage change
E) A client who stopped into the office to pick up sample medications
Ans: A, B, C, D, E
All nurses must manage multiple client needs in a timely manner. Nurses must prioritize to determine the proper order of response. Maslow’s Hierarchy of Needs can be helpful to make that determination in certain circumstances. A client with chest heaviness potentially could be having a life-threatening condition needing attention immediately. Next, the client in the exam room needs vital signs and a history of present illness before the physician enters. To maintain the flow of the office, this client is a priority. Next, the nurse would answer the question of the client on the phone who may otherwise incorrectly ingest a double dose of medication. Next, a client needs to be called with medication dosage change. Lastly, the client in the office who has come to obtain sample medication needs medication instruction on dosage and side effects.



30. A new client charting system is in the education phase at a healthcare facility. Much discussion has been prompted regarding the new system. With which statement does the nurse best exhibit the integrated leader/manager traits?
A) “Let’s look at the daily benefits of using the new technology on the clinical unit.”
B) “I am not used to the new technology, but if it better serves the client and enables easy sharing of client authorized records, I see a benefit.”
C) “New technology may be costly up front but will serve us well in the future.”
D) “I do not believe that this technology will be helpful in caring for a client because it often is down during peak use times and is difficult to train for.”
Ans: B
The traits of an integrated leader/manager combine understanding the daily operations on a clinical unit while seeing the big picture and thinking in the long term. Better serving the client and sharing records as needed demonstrates the willingness to think positively and take risks on improvement for the future. Option A and C only look at one aspect of leadership/management. Option D is a negative statement.


1. Which of the following is one of the four categories of client needs identified by the National Council of State Boards of Nursing?
A) Maintenance of function
B) Restoration of wellness
C) Psychosocial integrity
D) Reduction of fear and worry
Ans: C
The National Council of State Boards of Nursing identifies four categories of client needs as the structure for its test plan: safe and effective care environment, health promotion and maintenance, psychosocial integrity, and physiologic integrity. Nursing care provides skills that help restore wellness, especially during an acute illness, or maintain as much function as possible. The supportive relationship that develops reduces fear and worry.



2. Which of the following is a component of nonverbal communication?
A) Paralanguage
B) Hearing acuity
C) Interpersonal attitudes
D) Listening
Ans: A
Nonverbal communication consists of components such as kinesics, paralanguage (vocal sounds that communicate a message), proxemics (use of space when communicating), touch, and silence. Hearing acuity, interpersonal attitudes, and listening are variables that affect verbal communication.



3. Which of the following is a purpose of affective touch in the context of nursing?
A) Demonstrating concern
B) Providing contact for performing procedures
C) Encouraging verbal communication
D) Providing brief periods for response
Ans: A
Affective touch is touch used to demonstrate concern or affection. Task-oriented touch involves the personal contact that is needed for performing nursing procedures. Silence is the art of remaining quiet. Encouraging verbal communication and providing a brief period during which clients can respond to a question are therapeutic uses of silence.



4. Which of the following means of comprehending new information best describes a cognitive learner?
A) The learner learns through information that appeals to feelings.
B) The learner likes to learn by doing.
C) The learner learns by combining three styles of learning.
D) The learner processes information by listening to facts.
Ans: D
The cognitive learner processes information best by listening to or reading facts and descriptions. The affective learner is more attuned to learning when presented with information that appeals to his or her feelings. The psychomotor learner typically likes to learn by doing. A combination of the three styles tends to optimize learning, although most people favor one style of learning.



5. Which of the following is a reason why silence is considered therapeutic?
A) It demonstrates concern or affection.
B) It communicates caring and support.
C) It encourages a client’s verbal communication.
D) It is therapeutic when a client is uncomfortable.
Ans: C
Silence is the art of remaining quiet. One of its therapeutic uses is to encourage a client’s verbal communication. Affective touch is typically used to demonstrate concern or affection. Its intention is to communicate caring and support. The nurse use affective touch therapeutically in many situations, including when a client is uncomfortable.



6. Advocacy and support are activities associated with which learning style?
A) Cognitive
B) Cultural
C) Psychomotor
D) Affective
Ans: D
The affective learner learns best when presented with information that appeals to his or her feelings, beliefs, and values. Cognitive learners process information best by listening to or reading facts and descriptions. The psychomotor learner prefers to learn by doing. There is no learning style classified as cultural.



7. Which of the following is a person’s intellectual ability to remember and apply new information?
A) Learning style
B) Learning needs
C) Motivation
D) Learning capacity
Ans: D
Learning capacity is a person’s intellectual ability to understand, remember, and apply new information. Learning style is the manner in which a person best comprehends new information. Learning needs are the skills and concepts that the client and family must acquire to restore, maintain, or promote health. Motivation is the desire to acquire new information.



8. Which of the following is a positive interpretation of body language?
A) Clenched jaw
B) Tilt of head
C) Arms crossed
D) Rubbing nose
Ans: B
An example of a positive interpretation of body language is the tilt of the head. Negative examples of body language include a clenched jaw, crossed arms, and rubbing the nose.



9. Which type of learner processes information more adequately by listening or reading facts?
A) Social
B) Psychomotor
C) Affective
D) Cognitive
Ans: D
Cognitive learners process information best by listening to or reading facts and descriptions. There is no category of social learner. The psychomotor learner prefers to learn by doing. The affective learner learns best when presented with information that appeals to his or her feelings, beliefs, and values.



10. Which of the following is a client responsibility in the nurse–client relationship?
A) Remain nonjudgmental.
B) Comply with the therapeutic regimen.
C) Function as an advocate.
D) Perform prescribed skill safely.
Ans: B
Complying with the therapeutic regimen is a client responsibility. Remaining nonjudgmental, functioning as an advocate, and performing a prescribed skill safely are nurse responsibilities.



11. The nurse is caring for a client who is hard of hearing. The nurse is in the room during client and physician discussion and will relate the information to the client’s power of attorney. Which term best describes the role the nurse is assuming?
A) Friend
B) Caregiver
C) Leader
D) Coach
Ans: B
When the nurse assists the client is relaying information to the family, the nurse is in the role of the caregiver. The caregiving role includes a close relationship and becomes a client’s guide, companion, and interpreter. The nurse loses perspective when in the role of the friend. The nurse can be a leader and a coach; however, in the situation stated, the best answer is caregiver.



12. The nurse enters the client’s room and assesses that the client’s affect appears sad. The client is sitting near the window, staring into the distance with a tear in the eye. The nurse approaches and places a hand on the client’s shoulder asking for client thoughts. What type of emotion is the nurse projecting?
A) Sympathy
B) Empathy
C) Ambivalence
D) Pity
Ans: B
The nurse is projecting empathy. Empathy is an intuitive awareness of what the client is experiencing. Nurses perceive the client’s emotional state and provide support. Sympathy is the projection of understanding the way one may feel, many times by having gone through the experience as well. Ambivalence projects conflicting feelings and uncertainty. Pity is projects a feeling of sorrow.



13. Which of the following is least effective in encouraging a client to follow a medication regimen?
A) Provide information on the medications prescribed
B) Instruct the family members on treatment regimen
C) Discuss perspective from the nurse’s personal experience
D) State potential consequences if medication regimen in not followed
Ans: C
When encouraging a client to follow a medically prescribed medication regiment, the nurse is least effective when including personal experiences and the nurse’s own choices. The most effective strategy is providing information on the medication regimen, including family member in the treatment regimen to support the client and to provide information on the consequence if the medication regimen is not followed. Ensuring that clients have all of the information to make an informed decision is a nursing role.



14. The charge nurse delegates the administration of a pain medication to a practical nurse. Which statement, made by the charge nurse, indicates that the final step in the delegation process has been completed?
A) “Did you document the administration of the pain medication on the medication record?”
B) “Is the physician aware of the client’s need for pain medication?”
C) “What is the client’s pain level since administering the pain medication 30 minutes ago?”
D) “Have you ever administered this type of pain medication previously?”
Ans: C
The final step in the delegation process is to ensure that the task has been completed and determine the resulting outcome of the action. In this case, it is ensuring the medication is giving and assessing for pain relief. The other steps may be completed in the delegation process, but they are not completed last.



15. The nurse has been caring for a client and family for 6 months in the long-term care facility. Which of the following nursing actions is appropriate during the terminating phase of the nurse–client relationship? Select all that apply.
A) Teaching the client and family about care needs at home
B) Providing personal contact information if further guidance is needed
C) Accepting personal gifts of gratitude from the client
D) Relaying well wishes from the staff
E) Arranging health related services to support home care
F) Coordinating medication regimen for home care
Ans: A, D, E, F
The terminating phase occurs when the client’s health problems have improved and nursing services in the long-term care facility are no longer necessary. The nurse’s role becomes transitioning the client and family to home care. Teaching about needs, arranging health related services, and coordinating medication regimen for home care are all appropriate. Also, relaying well wishes from the staff shows the caring nature of the staff and highlights the nurse–client relationship while in the facility. It is typically not appropriate to accept personal gifts or exchange personal contact information with the client.



16. Which of the following nurse statements is completed in the working phase of the nurse–client relationship?
A) “Tell me about your religious beliefs during this season of the year.”
B) “I will put a chair in the bathroom so you can begin personal care. I will return to assist you as needed.”
C) “I understand that you are feeling anxious about going home. Let me assess you before we talk.”
D) “Let’s talk about a way to assist you to a standing position so you can walk in the hall.”
Ans: B
During the working phase of the nurse–client relationship, the nurse and the client puts the mutually developed plan into action. Each person shares in performing the task that leads to the desired outcome, which supports the client’s independence. In the introductory phase, the nurse should be gathering information regarding religious beliefs. In the terminating phase, the client may feel apprehensive about assuming independent activity or self-care. Developing the plan with activities such as assisting to a standing position to walk in the hall is completed in the introductory phase.



17. The nurse is caring for a client and family who are awaiting the results of a diagnostic test. Which of the following acts, made by the nurse, best demonstrate therapeutic nonverbal communication?
A) The nurse listens to the client’s frustration of waiting for test results.
B) The nurse smiles and rubs the shoulder of the client.
C) The nurse is silent while caring out her nursing duties.
D) The nurse shrugs the shoulders when asked when testing results will return.
Ans: B
A smile and rub of the client’s shoulder is a nonverbal gesture that the nurse understands the client’s situation. Listening to client frustration is an activity that affects verbal communication because, therapeutically, there is a response. Silence can be therapeutic when the attention is with the client, not the nursing duties. Shrugging the shoulders can be perceived as indifferent and not caring.



18. The nurse is instructing a client in a crowded semiprivate room. The nurse approaches and moves equipment to allow for a comfortable conversation. At which distance should the nurse stand?
A) Within 1 feet
B) 2 to 3 feet
C) At least 5 feet
D) Over 6 feet
Ans: B
Proxemics refers to the use of space when communicating. Most Americans feel comfortable when individuals are 2 to 3 feet away.



19. Which nursing action is most therapeutic when a client says, “My daughter wants me to go to a nursing home to get rid of me; I am just a burden.”
A) Pull up a chair and sit down to talk.
B) Offer self and discuss family behaviors the nurse sees.
C) Explore past relationship issues using reminiscence therapy.
D) Offer to call the daughter in to discuss the issues.
Ans: A
The nurse must respond delicately to an emotional client. The most therapeutic action for the nurse is to pull up a chair and sit down to talk. When assuming a seated position, it allows the nurse to be at eye level instead of overhead, which places the client in the position of vulnerability. Offering of self is therapeutic but not to discuss the family through the nurse’s eye. Exploring past relationships does not focus on the issues today. Offering to call the daughter would not be done until further information is obtained.



20. The nurse cares for multiple ethnic populations. Which of the following examples best demonstrates a facility adhering to The Joint Commission requirements that healthcare workers facilitate communication with all clients?
A) The facility requires a family member of a non–English-speaking client be present to discuss healthcare issues with a physician and member of social service.
B) Language dictionaries are placed in the facility library with open access for staff.
C) The facility requests bilingual staff and community members to voluntarily provide contact information for interpreter services.
D) The facility subscribes to an online interpreting service.
Ans: C
It is a requirement of The Joint Commission that agencies develop a system to provide aids and services to any client with literacy needs and also to provide language interpreting and translation services. The best way to demonstrate this requirement is by reaching out to staff and community members to provide personal interpreting services. It is not appropriate to require a family member, if available, to be present. The other options may be helpful in communicating with clients, but personal services are optimal.



21. The nurse is caring for a client who has been diagnosed with a cerebral vascular accident and subsequent expressive aphasia. In which manner does the nurse best promote communication?
A) Ask open-ended questions and allow time for the client to respond.
B) Use head nods and shakes to convey answers to questions.
C) Use hand gestures to facilitate nursing care.
D) Use a picture board with common responses.
Ans: D
For clients with aphasia, it is most helpful to have a picture board with responses to convey meaning. This decreases some frustration and allows the client to have some control over care. Asking closed-ended questions with limited responses and allowing for additional response time is appropriate. Head nods and hand gestures are limited ways of communication.



22. The nurse is caring for a client who is newly diagnosed with atrial fibrillation. The client states he has many questions. At what point in the client contact experience does assessment for learning begin?
A) During a morning assessment
B) When presenting the client with a brochure
C) Once the physician confirms the diagnosis
D) At the time of arrival to the hospital for care
Ans: D
The time of the initial assessment for learning begins when the client arrives at the hospital. Even when the client is in the emergency department, doctors and staff are explaining testing and procedures. As a new medical diagnosis is confirmed, teaching continues with information about the disease process, new medication, and treatment regimen.



23. The nurse is discharging a client with an indwelling Foley catheter. Which instructional method is best when teaching a psychomotor learner about the care necessary?
A) Provide a booklet that outlines directions.
B) Provide the phone number of a nursing agency to assist with care.
C) Provide testimonials of others who have had a Foley catheter at home.
D) Provide the Foley catheter and equipment to handle and practice care.
Ans: D
A psychomotor learner prefers to learn by doing. Providing equipment enables the learner to use the equipment and reinforces the necessary care. The booklet would be appropriate for the cognitive learner. A nursing agency is most often ordered by a physician for nursing care but is not a daily service. Testimonials are effective for affective learners.



24. A nurse is caring for a client who is newly diagnosed with cancer and receiving a peripherally inserted central catheter (PICC). Upon analysis, the nurse determines that the client is an affective learner. Which type of learning situation would the client learn from best?
A) Having the client make a poster with the equipment from the PICC line
B) Having the client prepare notes related to the PICC line to be discussed with the physician
C) Having the client attend a group support meeting of people with PICC lines
D) Having the client look online for information related to the PICC line
Ans: C
An affective learner learns best when the information is presented with consideration of the client’s thoughts/feelings, values, or beliefs. Having a client attend a group support meeting with individuals having similar life struggles provides the opportunity for the client to learn how best to live with the new diagnosis and care for themselves. Making a poster with equipment is helpful for a psychomotor learner. Preparing notes and learning online is helpful for a cognitive learner.



25. A wound care nurse approaches a client to instruct in home care needs. In which clinical scenario would the nurse delay teaching due to learning readiness?
A) The client says that a grandchild will be in soon.
B) The client is eating breakfast.
C) The client is anxious about physical therapy.
D) The client is meeting with the priest.
Ans: C
Learning readiness pertains to the optimal time for learning. This occurs when a client is in a state of physical and psychological well-being. Being anxious about an upcoming activity distracts the client from learning. Waiting until after the activity allows the client to be more focused on the teaching. Nurses may decide to delay teaching due to visiting family, eating breakfast, and meeting with a priest, but it is not from learning readiness.



26. The nurse is evaluating the comprehension of a client’s knowledge of the administration of Lovenox, an anticoagulant. Which method provides the best feedback?
A) Having the client explain the medication and injection site
B) Having the client demonstrate the injection technique on an orange
C) Having the client watch the nurse prepare the medication and administer it
D) Having the client prepare the syringe and independently administer the injection
Ans: D
Having the client prepare the syringe and independently administer the injection is the “show back” portion of learning comprehension because it includes demonstrating the skill. By independently demonstrating, the nurse is able to evaluate the knowledge base and skill. Having the client watch the nurse administer the medication is in the teaching process. Having the client explain the medication and injection site or administer the injection into an orange demonstrates parts of the skill but does not allow the nurse to evaluate the entire skill.



27. The nurse is employed at a diabetic clinic and is assisting a client with maintenance of blood glucose status. When assessing nurse–client responsibilities, which responsibility does the nurse most expect of the client?
A) Be courteous to others.
B) Comply with the set regimen.
C) Be nonjudgmental.
D) Possess knowledge.
Ans: B
The nurse most expects the client to comply with the set regimen. The other options are nursing responsibilities.



28. The nurse is preparing a community education program about a new treatment for prostate cancer. At what level would the nurse prepare the distributed educational materials?
A) Upper grade school, 4th to 6th grade level
B) High school, 10th to 12th grade level
C) Middle school, 7th to 9th grade level
D) College, over the 12th grade level
Ans: C
When preparing educational materials for the general population, the language or words used should be at the middle school, 7th to 9th grade level.



29. The nurse is caring for a geriatric client who has decided to move to a skilled nursing facility. The nurse assisted with the arrangements and, when leaving the room, touched the client on the shoulder. Which therapeutic technique was the nurse demonstrating?
A) Therapeutic communication
B) Affective touch
C) Silence
D) Task-oriented contact
Ans: B
Affective touch is used to demonstrate concern or affection. Its intention is to communicate caring and support. Therapeutic communication and silence can be helpful in this situation but does not it into the scenario. Task-oriented “touch” involves the personal contact that is required when performing nursing procedures.



30. Which of the following teaching scenarios best illustrates the nurse providing informal teaching on a low-sodium diet?
A) The nurse discusses dietary guidelines while the client watches a cooking show on television.
B) The nurse, client, and spouse review dietary orders on the discharge instructions.
C) The nurse and client discuss the sodium contained in prepared canned soup.
D) The nurse and client meet with a dietician to discuss ways of limiting sodium.
Ans: A
Informal teaching is unplanned and occurs spontaneously such as when the client is watching television and a teaching moment occurs. The remaining options were formal teaching to meet the goal of dietary teaching on a low-sodium diet.



31. An experienced nurse is evaluating a new nurse to the unit who is providing discharge instructions to an adult client. The experienced nurse views the following: The nurse approaches and decreases the volume on the television and then sits beside the client, presenting the information to the client and spouse. The nurse states, “You are to take Cipro 250 mg, two tablets b.i.d. A regular diet is ordered, and you are to follow up with your physician in 2 weeks. Here is printed information on the medication ordered.” The nurse obtains appropriate signatures and leaves. Which point would the experienced nurse address?
A) The nurse should use shorter sentences when teaching.
B) The nurse should improve professionalism and stand.
C) The nurse should minimize medical terms when teaching.
D) The nurse should continue with the same method without changes.
Ans: C
When teaching adult clients, it is best to minimize technical terms and medical jargon (“bid” for example) whenever able. The nurse used appropriate sentence length. Sitting beside the client is appropriate, and it is best to reduce noise and distraction by decreasing the volume of the television. With minimal change, the new nurse can improve her teaching skill.



32. The charge nurse in a long-term facility is addressing a breach in care with a client’s family. Which body language would the family interpret as being sincere in the statement?
A) Open hands
B) Downcast eyes
C) Shifting from foot to foot
D) Steepled fingers
Ans: A
Open hands is a form of body language representing sincerity. This body language shows that the staff and facility care for the quality of care of the client and are open about the details of care. Downcast eyes denotes remorse. Shifting from foot to foot denotes a desire to get away or avoid the discussion. Steepled fingers is interpreted as an authoritative approach.



33. The nurse is providing therapeutic communication while changing a client’s linen. The client states, “Every time I urinate, I still feel the need to urinate again. This is so disappointing.” The nurse states, “You don’t feel that you are emptying your bladder.” Which communication technique has the nurse used?
A) Open-ended questioning
B) Paraphrasing
C) Reflecting
D) Broad opening
Ans: B
Paraphrasing restates what the client is saying to demonstrate listening. This communication technique also allows the client to offer further information on the subject. Open-ended questioning provides an open-ended question for the client to provide further information. Reflecting states the content back to the client and confirms that the nurse is following the conversation. A broad opening starts the interaction and relieves tension before addressing other issues.



34. The nurse is caring for a client who received a poor prognosis when the physician made rounds. The client is quiet, tearful at times, and prefers to be in a darkened room. The nurse observes a nursing assistant entering the room, turning on the lights, and stating “Are we ready to get out of bed yet, the day is half over?” When addressing the statement of the nursing assistant, which communication technique would the nurse be most correct to discuss?
A) Giving disapproval
B) Belittling
C) Using clichés
D) Patronizing
Ans: D
Patronizing treats the client condescendingly as if incapable of making a decision. Giving disapproval holds the client to a rigid standard and is sarcastic in response. Belittling disregards how the client is responding as an individual and groups him or her with others in the similar position. Using clichés provides worthless advice and curtails exploring alternatives.



35. The student nurse is providing skilled care for a palliative care client. The client is bedbound, requiring skin care during bathing, oral care, and every 2 hours positioning. Which NCLEX-PN test category would the student anticipate finding questions related to this clinical care situation?
A) Health promotion and maintenance
B) Psychosocial integrity
C) Physiologic integrity
D) Safe and effective care environment
Ans: C
The role of the NCLEX-PN is to ensure that the student has sufficient knowledge to progress to a competent entry-level practitioner. Linking clinical experiences to classroom knowledge base is essential. This content falls under the physiologic integrity subcategory of basic care and comfort. This category tests the skill of the nurse in a clinical situation completing basic care needs. The health promotion and maintenance category has content areas including caring for individuals through life transitions. Psychosocial integrity includes caring for mental health needs and using therapeutic communication. Safe and effective care environment ensures appropriate nursing care and infection control.



36. Which of the following nursing statements, made to the client, best provides an example of a broad opening?
A) “Wow, the weather is looking nice outside.”
B) “Would you like your pills whole or cut in half?”
C) “So you live in a ranch-style home with a bathroom off your bedroom.”
D) “Oh, your daughter lives within walking distance of your home.”
Ans: A
A broad opening is intended to open communication on a common topic and relieve tension. Focusing on the weather provides that common topic to initiate communication. Further communication and specific topics flow from this point. Inquiring about medication administration is on a specific topic and in need of a specific response. The other options deal with specific topic points presented during a discussion.


1. You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately?
A) The client feels restless and hungry.
B) The client exhibits an increased urinary output.
C) The client’s heart rate is greater than 90 beats/minute.
D) The client’s respiratory rate is less than 20 breaths/minute.
Ans: C
A heart rate greater than 90 beats/minute or a respiratory rate greater than 20 breaths/minute will indicate that sepsis has occurred. Sepsis does not increase the client’s appetite or affect the client’s urinary output.



2. The nurse is giving an educational talk to a local parent–teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse’s best response to help prevent and control community-acquired infections?
A) “Encourage your family to adopt a healthy diet and exercise regimen.”
B) “Encourage your family to stop smoking.”
C) “Make sure your family has all their childhood immunizations.”
D) “Make sure your family has regular checkups.”
Ans: C
To help prevent and control community-acquired infections, nurses should encourage childhood immunizations. Vaccines stimulate the body to produce antibodies against a specific disease organism. The immunization protects children as well as adults who may not have developed sufficient immunity. Following a proper diet and exercise regimen and going for regular checkups are important, but these measures do not help prevent or control community-acquired infections. Smoking cessation does not reduce the risk of such infections either.



3. You are teaching a health class in the local public health center. What instructions should you provide as the single most important measure to prevent the spread of infection?
A) Minimal social contact
B) Regular immunizations
C) Thorough handwashing
D) Sufficient food intake
Ans: C
Hand hygiene remains the single most important measure to prevent the spread of infection. It reduces the number of transient and resident microorganisms. Sufficient food intake helps restore biologic defense mechanisms but does not prevent spread of infections. Although minimal social contact and regular immunizations may help prevent the spread of infection, especially community-acquired infections, these are not practical measures.



4. A nurse on your unit sustains a needlestick injury while caring for a client whose infectious status is unknown. What would be the best course of action for the nurse to follow?
A) Avoid notifying the supervisor of the injury until the client’s infectious status is confirmed.
B) Avoid revealing the identity of the client or source of blood.
C) Be tested for disease antibodies at appropriate intervals.
D) Document the injury in writing after the client’s infectious status is confirmed.
Ans: C
If a needlestick injury has occurred, the nurse should be tested for disease antibodies immediately and at appropriate intervals thereafter. The nurse should document the injury in writing immediately and should not wait until the client’s infectious status is confirmed. The nurse should also notify the supervisor of the injury immediately and identify the person or source of blood, if possible.



5. The nursing instructor is teaching beginning nursing students about infection. Toward the end of class, the instructor gives the students a scenario of a client with an infection who has developed fever and diarrhea. What should the student nurse instruct the client to avoid?
A) Tea and coffee
B) Ice water and broth
C) Fruit juices
D) Milk and gelatin
Ans: A
A client with fever and diarrhea should avoid tea, coffee, and carbonated beverages containing caffeine because these promote diuresis. The intake of ice water, broth, fruit juices, gelatin, and milk should be encouraged to add proteins and calories.



6. You are working on a gerontology unit. A family member calls and tells you he wants to bring the family in to see one of the clients on the unit. The family member is concerned because several of the family members have colds. What instructions should you provide to someone with a respiratory infection?
A) Avoid intake of frozen foods.
B) Avoid visiting older adults.
C) Avoid direct sunlight.
D) Avoid meats and other protein-rich foods.
Ans: B
The nurse should instruct anyone with respiratory infections to avoid visiting older adults until symptoms subside; older adults are more susceptible to infections because their defense mechanisms are less efficient. It is not essential for the client to avoid frozen or protein-rich foods or direct sunlight.



7. You are an intensive care unit nurse caring for a client with a transmissible spongiform encephalopathy. You know that this type of encephalopathy is caused by what type of infectious agent?
A) Prion
B) Protozoa
C) Helminth
D) Rickettsia
Ans: A
A prion is a protein that does not contain nucleic acid. Research suggests that normal prions present in brain cells protect against dementia. When a prion mutates, however, it is capable of becoming an infectious agent and altering other normal prion proteins into similar mutant copies. The mutant prions, which can be formed by genetic predisposition or acquired by transmission between the same or similar infected animal species, cause transmissible spongiform encephalopathies. Transmissible spongiform encephalopathies are not caused by protozoa, helminths, or rickettsias.



8. Which of the following would be considered a mechanical defense mechanism?
A) Cast
B) Coughing
C) Clothing
D) Sunscreen
Ans: B
Mechanical defense mechanisms are physical barriers that prevent microorganisms from gaining entry or expel microorganisms before they multiply. Examples are the skin and mucous membranes, physiologic reflexes (e.g., sneezing, coughing, vomiting), and macrophages. Casts, clothing, and sunscreen do not keep microorganisms from gaining entry to the body.



9. You have admitted a new client to your unit. This client has an open draining sore on his leg. What diagnostic test would you anticipate being ordered?
A) Platelet count
B) Culture and sensitivity
C) Sputum culture
D) Urinalysis
Ans: B
A culture identifies bacteria in a specimen taken from a person with symptoms of an infection. The source of the specimen may be body fluids or wastes, such as blood, sputum, urine, or feces, or the purulent exudate, collection of pus, from an open wound. A platelet count would not tell you about the infection. A sputum culture would not be indicated for a leg wound, nor would a urinalysis.



10. You are caring for a client with breast cancer who has been receiving chemotherapy. The client was admitted with an infected lesion on her left leg. The physician has ordered Neupogen. What will Neupogen do for this client?
A) Increase platelet count
B) Boost the immune system
C) Increase white blood cell production
D) Boost red blood cell production
Ans: B, C
Bone marrow transplantation or administration of drugs that boost white blood cell production, such as filgrastim (Neupogen), may help immunosuppressed clients. Neupogen does not increase the platelet count or boost red blood cell production.



11. A client with a Staphylococcus aureus infection present in a sacral pressure ulcer has received treatment with three courses of antibiotics without eliminating the infection. What does the nurse understand has occurred with the client?
A) The client has a multidrug-resistant strain of bacteria.
B) The client has been misdiagnosed and has another type of microorganism present.
C) Staphylococcus aureus cannot be treated by antibiotics.
D) Staphylococcus aureus is a fungus and must be treated with an antifungal agent, not an antibiotic.
Ans: A
Some bacteria, such as Staphylococcus aureus, Streptococcus pneumoniae, and Escherichia coli, are developing multidrug resistance, the ability to remain unaffected by antimicrobial drugs such as antibiotics. There are no facts to indicate the client has been misdiagnosed. Staphylococcus aureus is treated with antibiotics and is a bacterium, not a fungus.



12. A client is diagnosed with a viral illness and requests an antibiotic to “cure” his illness. When the request is refused by the physician, the client states to the nurse, “I will never get better.” What is the best response by the nurse?
A) “I will speak with the physician again. You will only get better while taking an antibiotic.”
B) “Prescribing antibiotics for a viral infection may result in drug-resistant bacteria.”
C) “You need to think positively, and you will get better soon.”
D) “Taking antibiotics when you don’t need them will make you sick.”
Ans: B
Causes of antibiotic resistance, a consequence of bacterial mutations that interfere with the mechanism of antibiotic action, are related to inappropriate prescription of antibiotics for viral (rather than bacterial) infection. Because viral infections are often self-limiting, with symptoms control, the client will get better. Indicating that the client is not thinking positively is a nontherapeutic comment. Option D is not an informative response.



13. The infection control nurse collects data that indicates an increase in the number of clients in the hospital with multidrug-resistant infections. What priority education should healthcare providers receive?
A) Using contact precautions on all clients in the hospital
B) Administering antibiotics to all clients prophylactically
C) Hand hygiene
D) Emptying trash cans immediately in client’s rooms
Ans: C
Infections with multidrug-resistant microorganisms are very difficult to destroy with current pharmacologic agents, increasing the need to be vigilant about performing hand hygiene measures. It is unnecessary to use contact precautions, administer antibiotics prophylactically, or empty trash cans immediately for the preventions of multidrug-resistant infections.



14. A client visits the clinic with the complaint of a circular rash on the upper right arm. The rash is diagnosed as tinea corporis. What type of infection does the nurse anticipate the client will be treated for?
A) Rickettsiae
B) Protozoans
C) Mycoplasma
D) Fungus
Ans: D
One type of fungal infection is superficial (dermatophytoses), which affect the skin, hair, and nails; examples include tinea corporis, or ringworm, and tinea pedis, also known as athlete’s foot. Rickettsiae, protozoans, and mycoplasma have different characteristics and transmission than fungus.



15. A client has received a diagnosis of Lyme disease. What does the nurse understand about the transmission of infection resulting in this disease?
A) The disease is spread by a prion.
B) The disease is spread by single-celled fungi-like microorganisms
C) The disease is spread by helminths
D) The disease is spread by arthropods.
Ans: D
Example of arthropods includes fleas, ticks, lice, mosquitoes, and mites. Some rickettsial diseases that are spread by arthropods include Lyme disease. Prions may mutate and can be formed by genetic predisposition or acquired by transmission between the same or similar infected animal species and are not the same as arthropods. The disease is not spread by single-celled fungi-like microorganisms or helminths.



16. A family member wants to donate blood for a client who needs a blood transfusion. What information from the family member would make them ineligible for donation?
A) The family member was serving in the military in England in 1993 for 2 years.
B) The family member had a surgical procedure 4 years previously for an inguinal hernia.
C) The family member received a blood transfusion 10 years previously at a hospital in Canada.
D) The family member takes an antihypertensive medication for control of blood pressure.
Ans: A
The American Red Cross bans blood collection from anyone who has lived in the United Kingdom for a total of 6 months or longer between 1980 and 1996, lived in various countries in Europe including while serving in the military since 1980, received a blood transfusion in the United Kingdom, or lived 5 or more years in various European countries from 1980 to the present. There is a higher risk among these potential donors for BSE or “mad cow disease.” The other answers are not exclusion criteria for donating blood.



17. A family member of a client in a long-term care facility asks the nurse why he cannot insert a catheter so the client will not develop skin breakdown from being wet. What should the explanation include when the nurse responds to the family member?
A) Catheters are no longer used for treatment of incontinence.
B) Older adult residents are able to have catheters inserted if the family requests them.
C) The invasive nature of the catheter provides a portal for infection.
D) If a catheter is inserted, it must be flushed with normal saline daily.
Ans: C
Catheters provide a portal for infection because they are invasive. Although catheters are not used as frequently in older adults for the control of urinary incontinence, there are some bed-confined clients who use them. Family requests for catheters may be considered, but physicians make the decision if it will benefit the patient. Catheters are not flushed daily with anything.



18. The nurse is caring for an older adult client who develops a fever, rash over the trunk, and back and complains of feeling achy and very tired. What should the nurse suspect is occurring with this client?
A) A roundworm infection
B) Bacterial meningitis
C) A urinary tract infection
D) An autoimmune response
Ans: D
Healthcare providers must carefully assess for symptoms in older adults that may indicate autoimmune responses (i.e., rash, malaise, fever, aching, etc.).



19. A client informs the nurse that she has been using a douche to cleanse the vagina on a daily basis and is now experiencing itching and burning in the vaginal area. What should the nurse explain to the client that occurs when the vaginal pH is changed?
A) It causes destruction of the normal flora of the vagina and allows the development of vaginal infections.
B) The bottle must be contaminated with bacteria, and when the pH is changed, it allows the bacteria to enter the vaginal area.
C) It will cause an allergic reaction in the vaginal area.
D) When the vaginal pH is changed, it allows cancer cells to spread from the vagina to the cervix.
Ans: A
The acid environment is unfavorable for the multiplication of pathogenic bacteria and fungi. A change in vaginal pH or destruction of the normal flora, however, can promote the development of a vaginal infection. Bacteria do not cause the vaginal pH to change; the pH change allows bacteria to grow. Change in vaginal pH does not cause an allergic reaction and does not allow the development of cancer cells.



20. A client is admitted to an acute care facility with a diagnosis of appendicitis. Which laboratory results demonstrate the client’s leukocytosis?
A) Hemoglobin of 12 mg/dL
B) Lymphocytes 1,500
C) Neutrophils of 3,150/mm3
D) White blood cell (WBC) count of 22,000 cells/mm3
Ans: D
The body manufactures more WBCs as needed, a process referred to as leukocytosis. The WBC of 22,000 cells/mm3 indicates an abundance of white blood cells. Hemoglobin does not represent the presence of infection. The lymphocytes and neutrophils are within normal range and do not demonstrate leukocytosis.



21. A client comes to the clinic and informs the nurse that he has a “painful area under his armpit.” The nurse observes a 2-cm raised area that is erythremic and has a white substance inside of it. What does the nurse suspect the patient may be experiencing?
A) A lesion
B) An abscess
C) A fluid-filled vesicle
D) A cancerous tumor
Ans: B
To prevent the spread of pathogens to adjacent tissues, a fibrin barrier forms around the injured area. Inside the barrier, a thick, white exudate (pus) accumulates. This collection of pus is called an abscess, which may break through the skin and drain or continue to enlarge internally. A lesion would not be filled with pus, nor would a cancerous tumor. A fluid-filled vesicle is associated with a viral type illness.



22. A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply.
A) Temperature of 102° F
B) Heart rate of 120 beats/minute
C) Respiratory rate of 24 breaths/minute
D) PaCO2 of 42 mm Hg
E) Blood pressure of 120/80 mm Hg
Ans: A, B, C
Two or more of the following characterize sepsis: temperature greater than 100.4° F (38° C), heart rate greater than 90 beats/minute, respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mm Hg, WBC count greater than 12,000 cells/mm3, or 10% immature (band) forms. Blood pressure is not an indicator of sepsis, and a PaCO2 of 42 mm Hg is not an indicator.



23. A client is admitted to the acute care facility for vomiting and diarrhea. An intravenous (IV) catheter is inserted for the delivery of IV fluids. A family member is with the client and observes the nurse enter the room and begin touching the IV site without washing his hands or wearing gloves. Why should the client and family member be concerned with the nurse’s actions?
A) The client will have an allergic reaction to the IV.
B) The nurse could develop the same symptoms.
C) The client will develop a nosocomial infection.
D) Dislodging of the IV catheter.
Ans: C
Nosocomial infections are infections acquired while receiving care in a healthcare agency that were not active, incubatory, or chronic at admission. They occur for many reasons. Hospitalized clients are more susceptible to infections than well people because they are exposed to pathogens in the healthcare environment; may have incisions or invasive equipment (e.g., IV lines) that compromise skin integrity; or may be immunosuppressed from poor nutrition, their disease process, or its treatment. Also, because healthcare personnel are in frequent and direct contact with many clients who harbor various microorganisms, the risk for transmitting pathogenic microorganisms between and among clients is high. Allergic reaction to the IV, the nurse developing the same symptoms, and dislodging of the IV catheter are not the priority concerns.



24. A client arrives at the clinic with the complaint that she is having a vaginal discharge after having sexual intercourse with her boyfriend 1 week ago. The patient is diagnosed with gonorrhea and given a prescription for treatment. What type of infection transmission does the nurse understand occurred?
A) Direct contact
B) Droplet
C) Airborne
D) Vehicle
Ans: A
The route of transmission for a sexually transmitted disease is by direct contact. An infected person transmits the infection to a susceptible person. A droplet transmission is a spray of moist particles within a 3-foot radius of an infected person. An airborne transmission is suspension and transport on air currents beyond 3 feet. An infection transmitted by vehicle is on or in contaminated food, water, objects, or equipment.



25. A client arrives at the emergency department complaining of severe diarrhea and vomiting that began after ingesting a hot dog at the ball park 6 hours ago. How does the nurse understand that the contaminated food was transmitted to the client?
A) Droplet
B) Airborne
C) Vehicle
D) Vector
Ans: C
Vehicle is the route of transmission for this client’s illness. It is found on or in contaminated food, water, objects, or equipment and can occur from eating or drinking tainted products. The route of transmission, droplet is by a spray of moist particles within a 3-foot radius of infected persons. Airborne is a route of transmission that is a suspension and transport on air currents beyond 3 feet. An infection by vector is found on infected animals or insect to susceptible persons.



26. A client comes to the clinic with complaints of fever, chills, and coughing and is found to be positive for influenza. The nurse is aware that the flu is transmitted from one infected person to another. What type of infection is this considered?
A) Localized
B) Generalized
C) Community acquired
D) Nosocomial
Ans: C
Community-acquired infections are transmitted from one infected species to another. Common signs and symptoms are the same as generalized plus organ-specific or disease-specific manifestations. Examples of the infections transmitted are influenza, chickenpox, and tuberculosis. Localized infection is confined to a small area such as a furuncle (boil). Generalized infection is a systemic or widespread infection in one or two organs such as urosepsis. A nosocomial infection is acquired in a healthcare agency.



27. The nurse is caring for a client who has acquired immunodeficiency disease (AIDS) and has developed oral thrush. What type of infection is the nurse aware that has developed due to the immunocompromised state of the client?
A) Acute
B) Chronic
C) Secondary
D) Opportunistic
Ans: D
An opportunistic or superinfection occurs among immunocompromised hosts. Examples would be yeast infections in the mouth, bladder infections, gastroenteritis, and Pneumocystis carinii. An acute infection has a sudden onset with serious and sometimes life-threatening manifestations. A chronic infection is an extended infection that resists treatment. A secondary infection is a complication of some other disease process that occurred first.



28. A client informs the nurse that he “thinks he is getting sick.” Chief complaint of the client is low-grade fever, headache, and “has no energy.” What stage of the infection does the nurse recognize the client is experiencing?
A) Incubation period
B) Prodromal stage
C) Acute stage
D) Convalescent stage
Ans: B
In the prodromal stage, the initial symptoms appear; they may be vague and nonspecific. Possible symptoms include mild fever, headache, and loss of usual energy. The incubation period does not exhibit any recognizable symptoms. The acute stage is when the symptoms become severe and specific to the affect tissue or organ. The convalescent stage is when symptoms subside as the host overcomes the infectious agent.



29. The nurse is caring for a group of five clients at the hospital. In order to control infections when caring for the group of clients, what intervention can the nurse perform?
A) Use standard precautions with all clients.
B) Only use standard precautions with clients who have an infection.
C) Wear a mask while taking care of all clients and changing the mask between clients.
D) Place the clients on isolation precautions.
Ans: A
Nurses and other healthcare personnel must take precautions to control infections when caring for all clients, regardless of diagnosis or infection status. These precautions are called standard precautions, measures for reducing the risk of transmitting pathogens from both recognized and unrecognized sources of infections. It is unnecessary to use a mask when caring for clients who do not have a droplet or airborne infection. Clients should not be placed in isolation unless they have an infection that could be transmitted to others.



30. The nurse gave a client an injection and, when attempting to recap the needle, sustained a needlestick injury to the finger. What is the priority action by the nurse?
A) Report the injury or exposure to the supervisor.
B) Document the injury in writing.
C) Receive instructions on monitoring potential symptoms and medical follow-up.
D) Receive the most appropriate postexposure prophylaxis.
Ans: A
Should needlestick injury or other exposure to a potential blood-borne pathogen occur, healthcare workers are advised to follow postexposure recommendations; report the injury or exposure to one’s supervisor immediately; document the injury in writing; identify the person or source of blood; obtain the HIV and HBV statuses of the source of blood, if it is legal to do so. Unless the client gives permission, testing and revealing HIV status are prohibited. Obtain counseling on the potential for infection. Receive the most appropriate postexposure prophylaxis; be tested for disease antibodies at appropriate intervals. Receive instructions on monitoring potential symptoms and medical follow-up.



31. The nurse is caring for a client with an abscess on his back. The nurse observes purulent drainage coming from the abscess. What type of specimen does the nurse anticipate the physician will order to determine the type of bacteria present in the exudate?
A) A sensitivity test
B) Test for ova and parasites
C) White blood cell (WBC) count
D) A culture
Ans: D
A culture identifies bacteria in a specimen taken from a person with symptoms of an infection. The source of the specimen may be body fluids or wastes, such as blood, sputum, urine, or feces, or the purulent exudate, collection of pus, from an open wound. A test for ova and parasites is a stool specimen that is examined for evidence of any forms in the infecting microorganism’s life cycle. A WBC count may determine that infection is present in the body but does not isolate the bacteria. A sensitivity test is done to determine which antibiotic inhibits the growth of a nonviral microorganism and will be most effective in treating the infection.



32. A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?
A) An induration of 12 mm
B) An uneven erythemic area
C) An induration of less than 1 mm
D) An induration of 4 mm
Ans: A
The size of the induration, not including the surrounding area of erythema, is measured in millimeters. The measurement determines whether the reaction is significant. For example, a tuberculin skin test is test is considered positive if the induration is 10 mm or greater in persons with no known risk factors for TB; smaller measurements are significant in certain risk groups, such as immunocompromised clients. The other answers are not indicative of positive results.



33. A client is hospitalized for an infected decubitus ulcer of the sacral area. The physician is planning to remove the dead and damaged tissue. What type of procedure will the nurse prepare the client for?
A) Application of a dry dressing
B) Debridement
C) Administration of filgrastim (Neupogen)
D) Inject antibiotics into the wound
Ans: B
Debridement is the removal of dead and damaged tissue surgically. Application of a dry dressing will not debride the wound, nor will the administration of Neupogen or injecting antibiotics into the wound.



34. A client is in the acute care facility for the administration of intravenous (IV) antibiotics to treat bacterial pneumonia. The client begins to have severe diarrhea 3 days after the IV antibiotics with abdominal cramping and pain. What does the nurse suspect the client has developed due to the antibiotic use?
A) Food poisoning
B) An allergic reaction to the antibiotic
C) A helminth infection
D) Pseudomembranous colitis
Ans: D
When a client is taking an antibiotic, a superinfection can result from overgrowth of microorganisms not affected by the drug. This can lead to a serious inflammation of the colon called pseudomembranous colitis accompanied by potentially life-threatening diarrhea. Report fever, abdominal cramps, and severe diarrhea immediately. The other distractors are incorrect and not related to the use of the antibiotics.
19. You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
A) A puncture at the radial artery
B) The trachea and bronchi
C) The pleural surfaces
D) A catheter in the arm vein
Ans: A
ABGs determine the blood’s pH; oxygen-carrying capacity; and levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.



2. The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about?
A) Raised temperature in the affected limb
B) Excessive capillary refill
C) Absent distal pulses
D) Flushed feeling in the client
Ans: C
When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. Absent distal pulses may indicate damage to the artery or a clot. When the contrast medium is infused, the client will sense a warm, flushed feeling.



3. You are a nurse in the radiology unit of your hospital. You are caring for a client who is scheduled for a lung scan. You know that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?
A) Bleeding
B) Iodine allergy
C) Dysrhythmias
D) Inflammation
Ans: B
During lung scans, a radioactive contrast medium is administered intravenously for the perfusion scan. Before the perfusion scan, nurses must assess the client to check for allergies to iodine. Laryngoscopy determines inflammation. Dysrhythmias and bleeding are possible complications of mediastinoscopy.



4. The nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates?
A) Cancer
B) Infection
C) Inflammation
D) Heart failure
Ans: B
Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.



5. Your client has just had an invasive procedure to assess the respiratory system. What do you know should be assessed on this client?
A) Watery sputum
B) Loss of consciousness
C) Respiratory distress
D) Masses in pleural space
Ans: C
After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space affect fremitus. General examination of overall health and condition includes assessing the consciousness of a client.



6. An 18-month-old child is brought to the emergency department by his parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?
A) Right upper lung
B) Left upper lung
C) Right lower lung
D) Left lower lung
Ans: A
Aspiration of foreign objects is more likely in the right main stem bronchus and right upper lung. The right mainstem bronchus is slightly higher and more vertical than the left, which is why foreign articles are often aspirated here first.



7. What happens to the diaphragm during inspiration?
A) It relaxes and raises.
B) It contracts and flattens.
C) It relaxes and flattens.
D) It contracts and raises.
Ans: B
During inspiration, the diaphragm contracts and flattens, which expands the thoracic cage and increases the thoracic cavity.



8. You are studying for a physiology test over the respiratory system. What should you know about central chemoreceptors in the medulla?
A) They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.
B) They respond to changes in the O2 levels in the brain.
C) They respond to changes in CO2 levels in the brain.
D) They respond to changes in O2 levels and bicarbonate levels in the cerebrospinal fluid.
Ans: A
Central chemoreceptors in the medulla respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid. Central chemoreceptors do not respond to changes in the O2 levels in the brain, changes in CO2 levels in the brain, changes in O2 levels, and bicarbonate levels in the cerebrospinal fluid.



9. What is the difference between respiration and ventilation?
A) Ventilation is the process of gas exchange.
B) Ventilation is the movement of air in and out of the respiratory tract.
C) Ventilation is the process of getting oxygen to the cells.
D) Ventilation is the exchange of gases in the lung.
Ans: B
Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells. Therefore, options A, C, and D are incorrect.



10. Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?
A) The two methods of perfusion are the bronchial and alveolar circulation.
B) The two methods of perfusion are the bronchial and capillary circulation.
C) The two methods of perfusion are the bronchial and pulmonary circulation.
D) The two methods of perfusion are the alveolar and pulmonary circulation.
Ans: C
The two methods of perfusion are the bronchial and pulmonary circulation. There is no alveolar circulation. Capillaries are the vessels that performs the perfusion regardless of which area of the lung they are in.



11. A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?
A) Cilia
B) Sinus cavity
C) Tonsils
D) Turbinates
Ans: C
Tonsils and adenoids do not contribute to respiration but protect against infection. Palatine tonsils are composed of lymphoid tissue. Cilia are fine hairs that move particles and liquid, preventing irritation and contamination of the airway. Sinuses are nasal cavity structures. Turbinates warm and add moisture to the inspired air.



12. The nurse is suctioning a client who is unable to expectorate respiratory secretions. At which point does the nurse expect the client to experience coughing?
A) When the catheter reaches the back of the pharynx
B) When the catheter enters the main bronchus of the lung
C) When the catheter reaches the point of the carina
D) When the catheter tickles the uvula
Ans: C
Upon the catheter stimulating the carina, coughing and even bronchospasm may occur. Productive secretions may be loosened and eliminated via the suction catheter. When the catheter reaches the back of the pharynx near the uvula, the gag reflex is initiated. The suction catheter does not reach the entrance of the lung.



13. A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority?
A) Acute Pain
B) Potential for Infection
C) Impaired Gas Exchange
D) Ineffective Airway Clearance
Ans: C
The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis Acute Pain is probable, gas exchange is a higher priority. Ineffective Airway Clearance is the least concern because the problem is with ventilation.



14. The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?
A) Blood gases
B) Complete blood count
C) Blood chemistry
D) Serum alkaline phosphate
Ans: A
Blood gases report the partial pressure of oxygen, which is dissolved in the blood. Normal readings are 80 to 100 mm Hg. By documenting oxygen levels in the blood, the nurse recognizes the current ventilation. The complete blood count provides information regarding number of blood cells, which can relate to the disease processes such as anemia and infection. The blood chemistry provides information on liver/renal function and electrolytes within the system. Serum alkaline phosphate is a laboratory test used to help detect liver disease and bone disorders.



15. The nurse is analyzing a client’s blood pH of 7.1. Which symptom would indicate that the patient’s body is working to stabilize?
A) Respirations are increasing.
B) Urine output is decreased.
C) Heart rate is regular.
D) WBC count is within normal limits.
Ans: A
Increased CO2 mechanism, which is present in body fluids primarily as carbonic acid, causes the pH to decrease below 7.4. As a homeostatic mechanism to normalize pH, the lungs eliminate carbonic acid by blowing off more CO2. Respirations increase to normalize pH. None of the other symptoms note a reflection of stabilizing blood pH.



16. The nurse is providing health education on the body’s ability to exchange oxygen and carbon dioxide through the alveolar capillary membrane. Which statement, provided by the nurse, is most correct when asked about diffusion during inspiration?
A) During inspiration, the concentration of oxygen is equal in both the alveoli and the capillaries.
B) During inspiration, oxygen diffuses from the arterial system through to the alveolar capillary membrane.
C) During inspiration, carbon dioxide provides the basis for all diffusion gradients.
D) During inspiration, oxygen is greater in the alveoli than in the capillaries.
Ans: D
During inspiration, oxygen-rich air from the environment enters the pulmonary system. During inspiration, the concentration of inspired oxygen is higher in the alveoli than in the capillaries, causing diffusion from the alveoli to the capillaries. Thus, the concentration of oxygen is not equal in the alveoli and capillaries. There is no diffusion from the arterial system after the oxygen diffuses from the alveoli to the capillaries. Carbon dioxide does not provide the basis for all diffusion gradients.



17. The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?
A) Medulla oblongata, cerebellum, and heart rate
B) Pons, cerebellum, and oxygen receptors
C) Medulla oblongata, mitral valve, and central receptors
D) Aortic arch, pons, and CO2 receptor sites
Ans: D
Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemoreceptors in the medulla and peripheral chemoreceptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad.



18. The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.
A) Oxygen is dissolved.
B) High blood pressure disrupts oxygen transport.
C) Oxyhemoglobin circulates to the body tissue.
D) All systemic oxygen is available for diffusion.
E) Adequate red blood cells are needed for oxygen transport.
Ans: A, C, E
Oxygen transport occurs by dissolving oxygen in the water in the plasma and combining oxygen with red blood cells (oxyhemoglobin). Normal red blood cell count is needed for oxygen transport. High blood pressure does not disrupt transport unless there is disruption in perfusion via a bleeding or occlusion. Dissolved oxygen is the only form which can diffuse across cell membranes.



19. The nurse is caring for a client with chronic obstructive pulmonary disease. The client calls the doctor and states having difficulty breathing and overall feeling fatigued. The nurse realizes that this client is at high risk for which condition?
A) Respiratory alkalosis
B) Respiratory acidosis
C) Metabolic acidosis
D) Metabolic alkalosis
Ans: B
Respiratory acidosis occurs when the body is unable to blow off CO2 due to the hypoventilation of disease processes such as COPD. An increase in blood carbon dioxide concentration occurs and a decreased pH causing acidosis. Respiratory alkalosis is a decrease in acidity of the blood and often caused by hyperventilation. Metabolic acidosis/alkalosis are disorders that affect the bicarbonate.



20. The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated?
A) Crackles
B) Rhonchi
C) Rubs
D) Wheezes
Ans: D
A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes are a whistling type of sound relating to the narrowing on the airway. A wheeze can have a high-pitched or low-pitched quality. Crackles, also noted as rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rhonchi are a course rattling sound similar to snoring usually caused by secretion in the bronchial tree. Rubs are secretions that can be heard in the large airway.



21. The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
A) The nursing assistant is assisting the client to a semi-Fowler’s position.
B) The nursing assistant is assisting the client to the side of the bed to use a urinal.
C) The nursing assistant is pouring a glass of water to wet the client’s mouth.
D) The nursing assistant is asking a question requiring a verbal response.
Ans: C
When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.



22. The nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates the resolution of the infection? Select all that apply.
A) Lung fields documented as clear in the bases.
B) Palpable vibrations over the chest wall when the client speaks.
C) Decreased fremitus when the client speaks “99.”
D) Dull sounds percussed over the lung tissue.
E) Bronchovesicular sounds heard over the upper lung fields.
Ans: A, B, E
The question asks for resolution or clearing of the infection; thus, normal respiratory status should be assessed. Lungs will return to clear breath sounds. Palpable vibrations will be felt as there is no blockage in the transmission. Bronchovesicular sounds will be noted over the upper lung fields. An increased fremitus is noted as the client speaks “99.” Dull percussed sounds indicate an area of consolidation.



23. The student nurse is learning breath sounds while listening to a client in the physician’s office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document?
A) Abnormal vesicular sounds
B) Normal bronchial sounds
C) Normal bronchovesicular sounds
D) Abnormal bronchial sounds
Ans: C
Air movement over the trachea and upper lungs is a normal finding for bronchovesicular sounds. The air movement is noted equally on inspiration as expiration. The other choices do not match type of breath sound for the location in question.



24. A client, experiencing respiratory distress, is ordered blood to be drawn for arterial blood gases (ABGs) via the radial artery. Before the blood is drawn, which circulation is assessed?
A) Carotid circulation
B) Ulnar circulation
C) Femoral circulation
D) Temporal circulation
Ans: B
Ulnar circulation is assessed using the Allen’s test. The Allen’s test is completed to assess blood supply through the ulnar and radial arteries. Noting both circulations is helpful when using an artery for the ABG draw. It is important to ensure adequate secondary blood flow to the hand other than through the radial artery in case the artery were to be damaged. No other circulation is assessed.



25. A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3 of 28 mEq/L. The nurse reports to the physician which finding?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic acidosis
D) Metabolic alkalosis
Ans: A
Respiratory acidosis would be reported to the physician citing the lab values. Analysis of the blood gases reveals that the client is acidotic with a pH under 7.35. Also noted is the PCO2 above the normal range of 30 to 40 mm Hg. The HCO3 is slightly elevated because the normal level is 22 to 26 mEq/L.



26. The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first?
A) Arterial blood gases
B) Pulmonary function test
C) Pulse oximetry
D) Chest x-ray
Ans: C
Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal values are 95% and above. Using this diagnostic test first provides rapid information of the client’s respiratory system. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.



27. The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?
A) “My study is scheduled for 10 AM, several hours after I eat.”
B) “I brought comfortable clothes and shoes for the test.”
C) “I am ordered a bronchodilator to note lung improvement following use.”
D) “I will breathe in through my mouth and out through my nose.”
Ans: D
The nurse would clarify the client’s statement of improper breathing technique. During a pulmonary function test using a spirometer, a nose clip prevents air from escaping through the client’s nose when blowing into the spirometer. All other statements are correct.



28. A client presents to the emergency department in respiratory compromise. The client’s temperature is 102.4° F, heart rate 88 beats/minute and regular, and blood pressure 138/76 mm Hg. The client is dyspneic, pale, and expectorating green-tinged sputum. The physician orders medications including antibiotics, antipyretics, nebulizer treatments, and IV fluids. A chest x-ray and sputum culture are to be completed. Which physician order would the nurse complete before beginning antibiotic therapy?
A) Chest x-ray
B) Sputum culture
C) Nebulizer treatments
D) Initiating IV fluids
Ans: B
The nurse would obtain a sputum culture for sensitivity before beginning antibiotic therapy. Obtaining a sputum culture after beginning antibiotics can skew results. Once the sputum culture results are returned, the antibiotic can be closely aligned to kill the organism, if present. The other orders can be prioritized according to client needs.



29. A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?
A) Fluoroscopy
B) Chest x-ray
C) Magnetic resonance imaging (MRI)
D) Computed tomography (CT) scan
Ans: A
Fluoroscopy enables the physician to view the thoracic cavity with all of its contents in motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial views of the lungs.



30. The nurse is instructing the client on the normal sensations, which can occur when contrast medium is infused during pulmonary angiography. Which statement, made by the client, demonstrates an understanding?
A) “I will feel a dull pain when the catheter is introduced.”
B) “I will feel light-headed when the contrast medium is introduced.”
C) “I will feel waves of nausea throughout the procedure.”
D) “I will feel warm and an urge to cough.”
Ans: D
During a pulmonary angiography a contrast medium is injected into the femoral artery. When the medium is infused, the client will feel a sense of warm and flushed with an urge to cough. The client will feel a pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during the procedure.



31. The nurse is working on a busy respiratory unit. In caring for a variety of clients, the nurse must be knowledgeable of diagnostic studies. With which diagnostic studies would the nurse screen the client for an allergy to iodine? Select all that apply.
A) Lung scan
B) Chest x-ray
C) Fluoroscopy
D) Pulmonary angiography
E) Bronchoscopy
F) Pulmonary functions test
Ans: A, C, D
The nurse must be well educated in screening clients before diagnostic procedures which include contrast medium for an allergy to iodine. A lung scan, fluoroscopy and pulmonary angiography all require contrast medium.



32. The nurse is caring for a client who states, “I am really worried about the thoracentesis. I know I won’t be able to sleep tonight.” Which statement is most helpful to the client at this time?
A) “Tell me what you are worried about.”
B) “Is there something that I can help you with?”
C) “Is there someone that you would like me to call to be with you?”
D) “The physician will see you before the procedure and can answer any questions.”
Ans: A
A thoracentesis is performed by inserting a needle into the wall under local anesthesia. The thoracentesis is often done at the bedside. Providing support to the client before, during, and after the treatment is a nursing responsibility. When the client states that he is worried, asking an open-ended question promotes communication and is most therapeutic. Asking if there is something that a nurse can do is a closed-ended question. Asking about calling someone to be with the patient makes the nurse seem uninterested. Talking with the physician closes communication with the nurse, making the nurse seem uninterested.



33. The nurse is caring for a client in the immediate post–thoracentesis period. In which position is the client placed?
A) In the supine position
B) Lying on the unaffected side
C) In the high Fowler’s position
D) Prone with a pillow under the head
Ans: B
Following a thoracentesis, the client remains on bed rest and typically lies on the unaffected side for at least 1 hour to promote expansion of the lung on the affected side. Lying flat in a supine position or prone does not promote expansion of the lung.



34. The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician’s order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
A) Tickle the back of the throat to produce the gag reflex.
B) Drink 8 oz of water to thin the secretions for expectoration.
C) Use the secretions present in the oral cavity.
D) Take deep breaths and cough forcefully.
Ans: D
Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.



35. A client arrives at the physician’s office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client’s sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document?
A) The client has a funnel chest.
B) The client has chronic respiratory disease.
C) The client has pneumonia in the bases.
D) The client needs a cough suppressant.
Ans: A
The question asks for a documentation based on inspection. A funnel chest, known as pectus excavatum, has the sternum depressed from the second intercostal space, and it is more pronounced on inspiration. The nurse would not diagnose chronic respiratory disease or pneumonia. The client would also not prescribe a cough suppressant.



36. A client arrives at the physician’s office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?
A) Tympanic
B) Resonant
C) Hyperresonant
D) Dull
Ans: D
A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyperresonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.



37. A client experiences a head injury in a motor vehicle accident. The client’s level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client’s respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?
A) The pons
B) The frontal lobe
C) Central sulcus
D) Wernicke’s area
Ans: A
The pons in the brainstem controls rate and depth of respirations. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke’s area is the area linked to speech.


1. A client has just been diagnosed with prehypertension. What would the nurse instruct this client to do to restore his blood pressure below hypertensive levels?
A) Increase iodine intake.
B) Decrease sodium intake.
C) Increase fluid intake.
D) Avoid over-the-counter decongestants.
Ans: B
The nurse should instruct clients with prehypertension to avoid or decrease sodium and iodine intake. Increasing fluid intake raises circulating blood volume and systemic vascular resistance. Over-the-counter decongestants decrease pulmonary congestion and not hypertension.



2. The nurse is caring for a client with malignant hypertension. What would be an appropriate nursing intervention for this client?
A) Monitor the client’s mental and emotional status every hour.
B) Monitor the blood pressure (BP) every few minutes by applying an automatic BP recording machine.
C) Monitor the client’s blood sugar every hour.
D) Monitor the client’s temperature every few minutes.
Ans: B
The nurse applies an automatic BP recording machine to the arm to measure the BP every few minutes. The nurse also keeps emergency equipment and drugs ready in case complications develop. Monitoring the client’s mental and emotional status, blood sugar, or temperature every few minutes will not reflect the sudden rise in BP of a client with malignant hypertension.



3. Which of the following diagnostic tests may reveal an enlarged left ventricle?
A) Echocardiography
B) Computed tomographic scan
C) Fluorescein angiography
D) Positron emission tomography (PET) scan
Ans: A
Echocardiography reveals an enlarged left ventricle. Fluorescein angiography reveals leaking retinal blood vessels, and a PET scan is used to reveal abnormalities in blood pressure. A CT scan reveals structural abnormalities.



4. A female client, aged 82 years, visits the clinic for a blood pressure (BP) check. Her hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about her blood pressure medicine?
A) Take the medicine on an empty stomach.
B) A possible adverse effect of blood pressure medicine is dizziness when you stand.
C) There are no adverse effects from blood pressure medicine.
D) A severe drop in blood pressure is possible.
Ans: B
A possible adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. Teaching should include tips for managing syncope and dizziness. You would not teach the client to take the medicine on an empty stomach.



5. You are caring for a client with hypertension who is experiencing complications. What diagnostic test evaluates the efficiency or inefficiency of the heart to pump blood?
A) Echocardiography
B) Chest radiography
C) Computed tomography scan
D) Multiple gated acquisition (MUGA) scan
Ans: D
The MUGA is a test that detects how efficiently or inefficiently the heart pumps blood. Echocardiography and chest radiography are used to reveal an enlarged left ventricle. The computed tomography scan is used to reveal abnormalities in blood pressure.



6. What is blood pressure?
A) The force produced by the volume of blood in arterial walls
B) The force produced by the volume of blood in the venous system
C) The measurement of cardiac output
D) The peripheral resistance of the cardiac output
Ans: A
Blood pressure (BP) is the force produced by the volume of blood in arterial walls. It is represented by the formula: BP = CO (cardiac output) × PR (peripheral resistance). This makes options B, C, and D incorrect.



7. You are teaching a health class at the local YMCA. What body system would you explain regulates arterial blood pressure?
A) Cardiovascular system
B) Immune system
C) Lymphatic system
D) Autonomic nervous system
Ans: D
The autonomic nervous system, the kidneys, and various endocrine glands regulate arterial pressure. The cardiovascular system, immune system, and lymphatic systems do not regulate arterial blood pressure.



8. The nurse in an oncology clinic notes that the client being treated has hypertension. What tumor is a predisposing condition for secondary hypertension?
A) Pheochromocytoma
B) Wilms’ tumor
C) Astrocytoma
D) Lymphoma
Ans: A
Predisposing conditions include kidney disease, pheochromocytoma (a tumor of the adrenal medulla), hyperaldosteronism (increased secretion of mineralcorticoid by the adrenal cortex), atherosclerosis, use of cocaine or other cardiac stimulants (e.g., weight-control drugs, caffeine), and use of oral contraceptives. Wilms’ tumors, astrocytomas, and lymphomas are not predisposing conditions for secondary hypertension.



9. You are part of a group of nursing students who are making a presentation on chronic hypertension. What is one subject you would need to include in your presentation as a possible consequence of untreated chronic hypertension?
A) Peripheral edema
B) Right-sided heart failure
C) Stroke
D) Pulmonary insufficiency
Ans: C
A stroke occurs if vessels in the brain rupture and bleed. If an aneurysm has developed in the aorta from chronic hypertension, it may burst and cause hemorrhage and shock. Options A, B, and D are not usually consequences of untreated chronic hypertension.



10. You are caring for a client diagnosed with secondary hypertension. What would be a predisposing condition for this diagnosis?
A) Use of valium
B) Hypoaldosteronism
C) Pancreatic disease
D) Use of oral contraceptives
Ans: D
Predisposing conditions include kidney disease, pheochromocytoma (a tumor of the adrenal medulla), hyperaldosteronism (increased secretion of mineralcorticoid by the adrenal cortex), atherosclerosis, use of cocaine or other cardiac stimulants (e.g., weight-control drugs, caffeine), and use of oral contraceptives. Secondary hypertension is not caused by the use of sedatives, hypoaldosteronism, or pancreatic disease.



11. The nurse is creating a community teaching demonstration focusing on the cause of blood pressure. When completing the visual aid, which body structures represent the mechanism of blood pressure?
A) Lung and arteries
B) Heart and blood vessels
C) Brain and sympathetic nervous system
D) Kidneys and autonomic nervous system
Ans: B
Blood pressure is the force produced by the volume of the blood in arterial walls. It is represented by the formula: BP = CO (cardiac output) × PR (peripheral resistance). To highlight the mechanism of cardiac output, a heart would be on the visual aid and blood vessels.



12. The nurse is caring for a client who is newly diagnosed with hypertension. The client states, “I do not understand what is causing my blood pressure to continue to rise.” Which information does the nurse recognize as the key structure in regulating arterial blood pressure?
A) Heart
B) Lung
C) Brain
D) Kidney
Ans: D
The body regulates blood pressure throughout the day. The components of the autonomic nervous system, the kidneys, and endocrine glands regulate arterial pressure. The heart is the pump sending blood throughout the system. The lungs exchange oxygen but do not affect blood pressure. The brain recognizes and processes sympathetic nervous system activity to raise blood pressure.



13. The nurse obtains a blood pressure of 136/86 mm Hg on morning assessment of a client with history of hypertension. Which pressure is of most concern when considering ventricular relaxation?
A) Central aortic pressure
B) Systolic pressure
C) Diastolic pressure
D) Central venous pressure
Ans: C
Diastolic blood pressure reflects arterial pressure during ventricular relaxation. It depends on the resistance of the arterioles and the diastolic filing times. Central aortic pressure is the blood pressure pumped from the left ventricle and measured at the root of the aorta. Systolic blood pressure is determined by the force and volume of blood that the left ventricle ejects. Central venous pressure reflects the blood pressure returning to the heart.



14. The nurse is working on a clinical research study, obtaining data evaluating central aortic systolic pressure and brachial arm systolic pressure. The client notes difference in the readings. Which response by the nurse is most accurate?
A) “The difference is due to machine calibration.”
B) “The difference is due to the location of pressure measurement.”
C) “The difference is due to the discomfort caused by the measurement procedure.”
D) “The difference is due to the constrictive force on the arteries when the measurement is taken.”
Ans: B
Central aortic systolic pressure results, reflecting pressure at the root of the aorta, can be documented as 30 mm Hg lower than when corresponding results obtained at the brachial arm. The differences are not due to machine calibration, discomfort, or constriction of the arteries.



15. The nurse is employed in a physician’s office and is caring for a client present for an annual exam. A blood pressure of 124/84 mm Hg is documented. Following revised guidelines for identifying hypertension, which educational pamphlet is help?
A) Increasing fluids for low blood pressure
B) Stress reduction to lower prehypertensive state
C) Use of beta-blockers for treatment of hypertension
D) Diagnostic testing for determining cardiac functioning
Ans: B
A blood pressure of 124/84 mm Hg is now considered to be in the lower range of prehypertension. Knowledge of stress reduction may be helpful in lowering the blood pressure without medication therapy. A blood pressure of 124/84 mm Hg is not considered a low blood pressure or in need of medication therapy due to hypertension. Diagnostic testing for cardiac functioning is not typical for a client with prehypertension.



16. Which of the following client scenarios would be correct for the nurse to identify as a client with secondary hypertension?
A) A client experiencing depression
B) A client diagnosed with kidney disease
C) A client of advanced age
D) A client with excessive alcohol intake
Ans: B
Secondary hypertension is an elevated blood pressure that results from or is secondary to some other disorder such as kidney disease, a tumor of the adrenal medulla, or atherosclerosis. Depression alone is typically not associated with hypertension. Advanced age and alcohol intake are considered factors for essential hypertension.



17. The nurse is caring for a client with long-standing hypertension. As a client advocate, which instruction is most helpful in preventing further complications?
A) Maintain a healthy diet of fruits and vegetables.
B) Focus on exercise at least twice a week.
C) Obtain a regular appointment with eye doctor.
D) Avoid use of caffeinated beverages.
Ans: C
When a client has long-standing hypertension, the high blood pressure damages the arterial vascular system. As a client advocate, the nurse must instruct on not only prevention but also on early identification of complications. Damages may occur to the tiny arteries in the eyes compromising vision. The most helpful instruction is to maintain a regular appointment with an eye doctor. The other options are good instruction for a healthy lifestyle.



18. Which of the following is the nurse most correct to recognize as a direct effect of client hypertension?
A) Renal dysfunction resulting from atherosclerosis
B) Anemia resulting from bone marrow suppression
C) Hyperglycemia resulting from insulin receptor resistance
D) Emphysema related to poor gas exchange
Ans: A
The nurse is most correct to realize high blood pressure damages the arterial vascular system and accelerates atherosclerosis. The effect of the atherosclerosis impairs circulation to the kidney, resulting in renal failure. Neither anemia, hyperglycemia, nor emphysema occurs as a direct effect of hypertension.



19. The nurse is screening a client at a health fair for hypertension. Which assessment data, provided by the client, would prompt the nurse to stress physician involvement? Select all that apply.
A) Fatigue
B) Constipation
C) Headache
D) Insomnia
E) Dysuria
F) Blurred vision
Ans: A, C, D, F
When assessing the client for symptoms of hypertension, the nurse should recognize that the client may note fatigue, headache, insomnia, and blurred vision. Other symptoms include dizziness, nervousness, nosebleeds, angina, and dyspnea. Constipation and dysuria are not signs of hypertension.



20. The nurse is obtaining a healthy history from a client with blood pressure of 146/88 mm Hg. The client states that lifestyle changes have not been effective in lowering the blood pressure. Which medication classification does the nurse anticipate first?
A) ACE inhibitors
B) Beta-blocker
C) Thiazide diuretic
D) Calcium channel blocker
Ans: C
Clients with hypertension, unable to be lowered by lifestyle changes, usually are placed on a thiazide diuretic initially. However, most people with hypertension will need two or more antihypertensive medications to reduce their blood pressure.



21. The nurse is instructing a client who is newly prescribed an antihypertensive medication. Which nursing instruction is emphasized to maintain client safety?
A) Use a pillbox to store daily medication.
B) Sit on the edge of the chair and rise slowly.
C) Do not operate a motor vehicle.
D) Take the medication at the same time daily.
Ans: B
The nursing instruction emphasized to maintain client safety is to sit on the edge of the chair before rising slowly. By doing so, the client reduces the possibility of falls related to postural hypotension. Using a pillbox to store medications and taking the medication at the same time daily is good medication management instruction. There is no reason when taking antihypertensive medications to restrict driving.



22. The physician is ordering a test for the hypertensive client that will be able to evaluate whether the client has experienced heart damage. Which diagnostic test would the nurse anticipate to determine heart damage?
A) Blood chemistry
B) Multiple gated acquisition scan (MUGA)
C) Chest radiograph
D) Fluorescein angiography
Ans: B
The nurse realizes that undiagnosed (untreated), long-standing hypertension can cause heart damage. The diagnostic test that best determines heart damage is the multiple gate acquisition scan (MUGA). This test is used to detect how efficiently the heart pumps. A blood chemistry determines electrolyte balance. A chest radiograph (chest x-ray) can provide details of the heart size through shading on the scan. Fluorescein angiography is an ophthalmologic test revealing leaking retinal blood vessels.



23. A nurse is assessing the blood pressure of a large adult client diagnosed with primary hypertension. To ensure an accurate blood pressure reading, the nurse follows which standard of care? Select all that apply.
A) Use the large adult blood pressure cuff.
B) Place the cuff midway between the acromion and olecranon process.
C) Vary the blood pressure reading sites every other day.
D) Obtain supine, sitting, and standing readings daily.
E) Document the results immediately after the reading is completed.
Ans: A, B, E
Standards of care require that the nurse use the proper-sized blood pressure cuff placed at the proper location on the arm at the appropriate time. Using a large adult blood pressure cuff is the correct size. Placing the cuff between the acromion process and olecranon process is the correct site. Documenting the blood pressure reading accurately after obtaining the reading is correct. Varying the blood pressure site and positioning every 1 or 2 days provides varied readings. Consistency needs to be maintained to draw accurate conclusions.



24. The nurse is caring for a client with accelerated hypertension. Which body system would the nurse assess to identify early signs of blood pressure progression?
A) Eyes
B) Kidney
C) Heart
D) Musculoskeletal system
Ans: A
Accelerated hypertension is defined as a markedly elevated blood pressure with symptoms of hemorrhages and exudates in the eyes. If the hypertension is untreated, accelerated hypertension progresses to malignant hypertension with symptoms of papilledema. Long-standing hypertension can produce changes in the kidney, heart, and musculoskeletal system.



25. The nurse is working on a busy cardiac unit caring for four hypertensive clients. Which client description would the nurse assess first because the client is at an increased risk for malignant hypertension?
A) A client with anorexia and history of no healthcare insurance
B) A client with liver dysfunction who drinks alcohol daily
C) A schizophrenic residing at an assisted living facility
D) A client with chronic asthma who uses a corticosteroid inhaler
Ans: A
Accelerated and malignant hypertension can occur in individuals who fail to maintain follow-up or comply with medical therapy. Those individuals who have no healthcare insurance often are unable to obtain the medical follow-up or afford the cost of medications to treat the hypertensive state. If the hypertension is untreated, symptoms and complication can rapidly follow. The other choices need further assessment but are not the priority.



26. The nurse is caring for a client who is ordered Hyperstat IV to decrease blood pressure. Which nursing consideration is a priority?
A) Elevate the head of the bed.
B) Use an automatic blood pressure recording machine.
C) Place a Foley catheter to monitor urine output.
D) Assess the client’s deep tendon reflex.
Ans: B
A nursing priority is to monitor the client’s blood pressure every few minutes. It is unrealistic to have the nurse manually assess the blood pressures. An automatic blood pressure machine is programed to assess the blood pressure and record the results for assessment. The other options may be completed; however, monitoring the blood pressure is the priority.



27. The nurse is volunteering at a community blood pressure screening. A client, never diagnosed with hypertension, presents with a blood pressure of 158/90 mm Hg. Which assessment questions, asked by the nurse, are appropriate? Select all that apply.
A) “Have you recently drunk a caffeinated beverage?”
B) “Did you have a beer after work?”
C) “Do you smoke?”
D) “Do you have a friend accompanying you?”
E) “Are you married and with children?”
Ans: A, C
At a community blood pressure clinic, the nurse would assess for common factors for a blood pressure to be elevated. Factors that can affect blood pressures readings include smoking or drinking coffee within 30 minutes of the reading. One beer after work should not affect the blood pressure reading, and some individuals may find it relaxing. Social situations are difficult to assess in a community blood pressure clinic. The client would be referred to having another blood pressure reading and, if elevated, referred to a physician.



28. The nurse is evaluating the types of medications prescribed for a client’s hypertension. Which of the following medication classifications establishes an action on vasoconstrictive hormones in the blood stream?
A) Beta-blocker
B) ACE inhibitor
C) Loop diuretic
D) Calcium channel blocker
Ans: B
The angiotensin-converting enzyme (ACE) inhibitor’s primary action is to prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstricting hormone in the blood. A beta-blocker blocks the beta-adrenergic receptors decreasing sympathetic nervous system stimulation. Loop diuretics excrete water from the loop of Henle, reducing circulating blood volume. Calcium channel blockers dilate coronary and peripheral arteries.



29. The nurse and a dietitian are instructing the client on a low-sodium diet needed to lower the blood pressure. Which question, asked by the nurse, is most important?
A) “Who eats meals with you?”
B) “How do you prepare your food?”
C) “Do you each three meals per day?”
D) “Do you snack in the evening?”
Ans: B
Asking the client how food is prepared, gives the nurse and dietitian the ability to judge the sodium content. If the client opens cans of food, typically, there will be elevated sodium content. If the client uses prepared foods or eats out regularly, there is sodium in the content. If the client uses fresh ingredients, sodium content is minimal. Asking about who eats with the client and their eating patterns are not as helpful in determining sodium content.



30. A client, newly prescribed a low-sodium diet due to hypertension, is asking for help with meal choices. The client provides four meal choices, which are favorites. Which selection would be best?
A) Toasted cheese sandwich on whole wheat toast with tomato soup
B) Creamed chipped beef over toast with mashed potatoes
C) Hot dog with ketchup and relish on whole wheat bun
D) Green pepper stuffed with diced tomatoes and chicken
Ans: D
Fresh vegetables are low in sodium with diced tomatoes (fresh) and chicken is a good low-sodium, high vegetable and protein selection. Cheese and soup (tomato and creamed) are high in sodium. Processed meats such as a hot dog and condiments such as ketchup are high in sodium.



31. Which ethnic background would the nurse screen for hypertension at an early age?
A) Asian population
B) Japanese population
C) Mexican population
D) African American population
Ans: D
The African American population is at the highest risk for development of hypertension. The other ethnic backgrounds have a lower risk.



32. The nurse is caring for a client with essential hypertension. The nurse reviews lab work and assesses kidney function. Which action of the kidney would the nurse evaluate as the body’s attempt to regulate high blood pressure?
A) The kidney retains sodium and water.
B) The kidney excretes sodium and water.
C) The kidney retains sodium and excretes water.
D) The kidney retains water and excretes sodium.
Ans: B
Hypernatremia (elevated serum sodium level) increases blood volume, which raises blood pressure. The kidney’s response to the elevation in blood pressure is to excrete sodium and excess water. Any retention of sodium and water would increase blood volume and, thus, blood pressure. Sodium and water move together.



33. Which of the following nursing diagnosis is the nurse most correct to choose when caring for a client with long-standing hypertension?
A) Impaired Gas Exchange
B) Activity Intolerance
C) Ineffective Tissue Perfusion
D) Risk for Decreased Cardiac Output
Ans: C
The nurse is most correct in choosing ineffective tissue perfusion for the client with long-standing hypertension. In hypertension, the extra work increases the size of the heart muscle. Eventually, the heart cannot meet the body’s metabolic needs limiting the perfusion to the tissues. Impaired Gas Exchange, Activity Intolerance, and a Risk for Decreased Cardiac Output may occur due to the ineffective perfusion.



34. The nurse is caring for a client with hypertension. The nurse is correct to realize that a 24-hour urine is ordered to determine if the cause of hypertension is related to the dysfunction of which of the following?
A) The thyroid gland
B) The adrenal gland
C) The pituitary gland
D) The thymus
Ans: B
The 24-hour urine collection specimen is ordered to determine dysfunction of the adrenal gland. The 24-hour urine detects elevated catecholamines. The other options are not evaluated by a 24-hour urine.