Final Exam MDC1 PDF

**A client in a long-term care facility is diagnosed with Cimex lectularius (bed bugs). The nurse expects which medication to be prescribed to the resident?** 2. **A nurse is educating a client with psoriasis about adalimumab, a biologic medication. What would be a priority to include in the...

**A client in a long-term care facility is diagnosed with Cimex lectularius (bed bugs). The nurse expects which medication to be prescribed to the resident?** 2. **A nurse is educating a client with psoriasis about adalimumab, a biologic medication. What would be a priority to include in the teaching?** 3. **A nurse assesses a client with actinic keratoses on the face. After reviewing treatment options, the client prefers topical therapy. Which medication can be used for this condition?** a. Imiquimod\ b) Tacrolimus\ c) Betamethasone\ d) Tretinoin **4. An older adult client with atopic dermatitis uses antihistamines to treat itching. What is the nurse's priority assessment?** a\) Assess the mouth for the presence of creamy white plaques on an inflamed base.\ b) Assess the skin for signs of secondary bacterial infection.\ c) Assess the respiratory status for signs of wheezing or shortness of breath.\ d) Assess the heart rate for signs of tachycardia or arrhythmias. **5.Which laboratory test finding is associated with osteoarthritis (OA)?** a\) Elevated rheumatoid factor\ b) Slightly elevated erythrocyte sedimentation rate (ESR)\ c) Decreased serum calcium levels\ d) Elevated C-reactive protein (CRP) **6.The nurse is reviewing the plan of care for a client with lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse suspect?** a\) Elevated serum calcium levels\ b) Low platelet count\ c) Possible antinuclear antibodies (ANAs) titer\ d) Elevated serum albumin levels **7.A client is describing how they manage their glaucoma medications at home. Which statement by the client would cause concern?** a\) \"I always check the expiration date before using my eye drops.\"\ b) \"I have a written schedule for my eye drops and I never forget more than one dose per day.\"\ c) \"I keep my eye drops in a cool, dry place to preserve their effectiveness.\"\ d) \"I try to space out my eye drops evenly throughout the day as prescribed.\" **8. A nurse is reviewing an order for chemotherapy; the nurse understands that this pharmacological intervention is appropriate for which musculoskeletal disorder?** a\) Osteoarthritis\ b) Osteosarcoma\ c) Rheumatoid arthritis\ d) Paget's disease **9. After teaching a client who has a fractured hip, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture?** a\) Fried chicken with cranberry juice and a vitamin D supplement\ b) Grilled salmon with a side of spinach and a glass of orange juice\ c) Cheeseburger with French fries and a milkshake\ d) Pasta with tomato sauce and a slice of garlic bread 10\. **A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response from the nurse?** a\) \"That pain will go away soon, it\'s just your body adjusting.\"\ b) \"Let's take a look at your residual limb and see if there\'s any sign of infection.\"\ c) \"On a scale of 0 to 10, how would you rate your pain?\"\ d) \"That's normal; it's called phantom limb pain.\" **11. A nurse cares for a patient who has a compound femur fracture. Which assessment should alert the nurse to take immediate action?** a\) Hypoxemia, dyspnea, and tachypnea.\ b) Stable vital signs and alert mental status.\ c) Pain rated 6/10 in the affected limb.\ d) Skin redness around the fracture site. **12. A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first?** a\) Assess the client's airway.\ b) Administer pain medication.\ c) Apply a dressing to the fracture.\ d) Obtain a chest X-ray. **13. A client sustains a fracture of one arm, and the provider applies a plaster cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department?** a\) Monitor neuromuscular status for decreased circulation and sensation in the extremity.\ b) Remove the cast if it feels tight or uncomfortable.\ c) Soak the cast in warm water to speed up drying.\ d) Apply ice to the cast to reduce swelling. **14. What intervention by the nurse would be best to prevent deep vein thrombosis (DVT) for an immobile client?** a\) Applying anti-embolism stockings.\ b) Encouraging increased fluid intake.\ c) Administering anticoagulants.\ d) Encouraging frequent position changes. **15. A client who is suspected of contracting a human immunodeficiency virus (HIV) gives birth to a full-term infant. Which laboratory study allows for faster and more accurate detection of HIV IgM and IgG antibodies?** a\) CD4+ cell count.\ b) HIV RNA PCR test.\ c) HIV enzyme immunoassay (EIA).\ d) Rapid HIV test. **16. A client presents with regular T-cells (Tregs) that are less active. The nurse understands that this deficiency puts the client at a higher risk of developing which of the following?** a\) Autoimmune disorders.\ b) Allergies.\ c) Cancer.\ d) Infectious diseases. **17. The nurse is caring for a client with an autoimmune disease. Which component of cell-mediated immunity is the problem?** a\) B-cells.\ b) Helper T-cells.\ c) Cytotoxic T-cells.\ d) Dendritic cells. **18. Which laboratory findings are acquired immune deficiency syndrome (AIDS) defining characteristics?** a\) CD4+ cell count less than 200/mm3 (0.2\*10⁹/l) or less than 14%\ b) HIV RNA PCR greater than 500 copies/mL\ c) CD8+ cell count less than 50/mm3\ d) CD4/CD8 ratio greater than 1:1 **19. The nurse is assessing a client's wound and identifies an abnormal passage connecting a body cavity and the skin; how does the nurse identify these findings?** a\) Abscess\ b) Fistula\ c) Erosion\ d) Sinus tract **20. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision. What does the nurse tell the provider about the event?** a\) The client's surgical wound has dehiscence.\ b) The client's surgical wound has eviscerated.\ c) The client has a wound infection.\ d) The client is experiencing normal post-operative pain. **21. Which of the following is a noninvasive radiographic scan to assess bone mineral density?** a\) Arthroplasty\ b) Dual-energy X-ray absorptiometry (DEXA)\ c) MRI\ d) Bone scintigraphy **22. The nurse is educating a client on the benefits of acupuncture. Which statement by the client would demonstrate the teaching was effective?** a\) \"Acupuncture may help with my pain.\"\ b) \"Acupuncture can completely cure my condition.\"\ c) \"Acupuncture is the only treatment I will need.\"\ d) \"Acupuncture involves surgery to fix my issue.\" **23. A nurse is caring for a client who is menopausal and asks the nurse about the use of herbal therapies to reduce her discomfort. Which statement would the nurse make?** a\) \"Many herbal products have not undergone testing for safety and efficacy.\"\ b) \"Herbal remedies are always safe and effective for menopausal symptoms.\"\ c) \"Only prescription medications can help alleviate menopause symptoms.\"\ d) \"Herbal therapies are regulated by the FDA for safety and effectiveness.\" **24. A nurse is teaching a client who has gout about dietary recommendations. Which of these should the nurse inform the client to avoid severe joint inflammation?** a\) High-purine foods\ b) Low-fat dairy products\ c) Fresh fruits and vegetables\ d) Whole grains **25. A nurse is teaching an older adult client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?** a\) \"The use of handrails should be available in the bathroom and halls to facilitate transfers.\"\ b) \"You should avoid using any assistive devices, as they are unnecessary.\"\ c) \"Keep your furniture close together to minimize walking distances.\"\ d) \"You can safely ignore any pain while walking; this helps build strength.\" **26. A client has been diagnosed with rheumatoid arthritis (RA) with sleep disturbances. What nursing intervention should the nurse suggest to help manage this condition?** a\) Balance activity with rest. this condition\ b) Encourage daytime naps to improve sleep.\ c) Avoid any physical activity to rest the joints.\ d) Use over-the-counter sleeping pills regularly. **27. What assessment finding is associated with acute wound?** a\) Acute wounds usually heal within days to weeks.\ b) Acute wounds show signs of chronic infection.\ c) Acute wounds have a thick, non-vascular appearance.\ d) Acute wounds are always associated with severe pain. **28. Identify the stage of the pressure injury from the image provided?**\ (Stage 2) **29. With the third intention of wound healing, what is most likely to occur?** a\) Delayed wound healing.\ b) Immediate closure of the wound.\ c) Rapid healing with minimal scarring.\ d) The wound heals by secondary intention. **30. A client applies a cold compress to her ankle injury based on the understanding that cold has which effect?** a\) Controls swelling\ b) Reduces muscle spasms\ c) Increases blood flow\ d) Enhances healing by increasing inflammation **31. What statement by the client indicates a need for further teaching about enoxaparin?** a\) \"I will take this medication only as prescribed by my primary care provider.\"\ b) \"I will notify my healthcare provider if I notice any unusual bruising or bleeding.\"\ c) \"I will inject the medication into the same spot every day.\"\ d) \"I will take this medication even if I feel well, to prevent clot formation.\" **32. A nurse is caring for a client who has rheumatoid arthritis (RA) receiving methotrexate. The client states, \"I am going to try to get pregnant.\" Which of these is the best response?** a\) \"You should wait at least 3 months after stopping methotrexate before trying to conceive.\"\ b) \"Pregnancy is not recommended while taking methotrexate due to possible birth defects.\"\ c) \"You can safely continue methotrexate until you are 4 months pregnant.\"\ d) \"There is no risk of pregnancy with methotrexate as long as the dose is low.\" **33. The nurse is preparing to administer medications to treat a client who has osteoarthritis (OA). What is the goal of the medication therapy?** a\) Cure the disease\ b) Reduce pain and inflammation\ c) Promote bone regeneration\ d) Prevent joint deformity **34. A nurse instructs a client having a total hip arthroplasty on their anticoagulant medication therapy. Which of these statements made by the client indicates that the client needs further instruction?** a\) \"I will take my anticoagulant medication every day as prescribed.\"\ b) \"I should avoid any activities that might increase my risk of bleeding.\"\ c) \"My anticoagulant will be interrupted for several days before surgery.\"\ d) \"I will notify my healthcare provider if I notice any signs of bleeding.\" **35. A client who has osteoarthritis (OA) is scheduled to start taking celecoxib. A nurse should teach the client to observe which of these negative side effects?** a\) Dark tarry stools\ b) Nausea and vomiting\ c) Shortness of breath\ d) Weight gain **36. A nurse is developing a plan of care with a client who has rheumatoid arthritis (RA) and is on leflunomide. A nurse should teach the client to observe which of these negative side effects?** a\) Decreased white blood cells\ b) Weight loss\ c) Increased appetite\ d) Joint stiffness **37. The client is a 70-year-old retired nurse who is interested in non-drug mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should be considered in the plan of care considering the client's expressed wishes?** a\) Chamomile tea and topical pain relief gel\ b) Methotrexate therapy and biologic agents\ c) Daily massage therapy and corticosteroid injections\ d) Frequent use of NSAIDs and rest **38. A nurse obtains the health history of a client with a fractured femur. Which factor identified in the patient's history would the nurse recognize as an aspect that may impede healing of the fracture?** a\) Osteoporosis\ b) Smoking\ c) Hypertension\ d) Diabetes **39. Which is an appropriate nursing intervention for psoriasis?** a\) Apply corticosteroids as ordered.\ b) Apply antifungal ointment to the affected area.\ c) Apply ice packs to reduce inflammation.\ d) Apply antibiotic ointment to prevent infection. **40. A nurse is applying a dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab forms?" Which of the following responses is most appropriate by the nurse?** a\) \"Wounds heal better when a moist wound bed is maintained.\"\ b) \"Dry wounds heal faster.\"\ c) \"Letting it dry will help prevent infection.\"\ d) \"It's better to let it scab over for a protective barrier.\" **41. A client has a pressure ulcer over the sacral area that is believed to have been caused by a shearing force at home. The family asks you to explain shearing force. What is the nurse\'s best response?** C. A superficial skin board getting pinched that is irritated and swollen. **42. A discharged obese client will require frequent dressing changes for a skin condition on his left foot. Which nursing action is the best to assess whether the client can perform this task?** a\) Determine if the client can reach the affected area.\ b) Instruct the client to change the dressing on the affected foot.\ c) Ask the client if they have a history of performing dressing changes.\ d) Assess the client's cognitive function to ensure understanding. **43. A client has a pressure injury on the coccyx measuring 5 to 3 centimeters. The nurse observes the bone and tendon at the base of the wound. How should the nurse document this wound?** a\) Stage III pressure injury\ b) Stage IV pressure injury\ c) Stage I pressure injury\ d) Unstageable pressure injury **44. The client has a pressure ulcer over the sacral area that occurs due to shearing force. The client's family asks the nurse to explain shearing force. Which response to the nurse is most accurate?** a\) \"Shearing occurs when a superficial skin fold is pinched in tissues irritated by pressure.\"\ b) \"Shearing occurs when the skin is stretched and distorted over the body, causing damage to blood vessels.\"\ c) \"Shearing occurs when the skin rubs against a rough surface, causing superficial irritation.\"\ d) \"Shearing occurs when the skin is compressed against the bone, reducing blood flow.\" **45. A nurse developed a care plan for a client to help prevent impaired skin integrity. The client has made sure that personnel change the client's position every two hours. In the stimulation phase of the nursing process, which of the following would the nurse do?** a\) Judge whether the interventions achieve the staged outcome.\ b) Reassess the client's skin to evaluate for any signs of breakdown.\ c) Record that the interventions have been performed as planned.\ d) Ensure that all appropriate documentation is completed. **46. When should a nurse wear eye protection?** a\) When transporting a cerebrospinal fluid specimen to the lab.\ b) When assisting a client with eating.\ c) When caring for a client in isolation.\ d) When administering oral medications. **47. Which client is at the greatest risk for developing osteoporosis?** a\) A sedentary 65-year-old woman who smokes daily.\ b) A 45-year-old man who exercises regularly.\ c) A 55-year-old woman with a balanced diet.\ d) A 60-year-old woman who takes vitamin D supplements. **48. A nurse has seen several clients at a Community Health Center. Which of the clients would be the most at risk for developing an infection?** a\) Older adults with several chronic illnesses.\ b) A young adult with seasonal allergies.\ c) A middle-aged client with no significant health problems.\ d) A pregnant woman in her second trimester. **49. Which of the following crutch walking is used for partial weight bearing?** a\) Two-point gait\ b) Three-point gait\ c) Four-point gait\ d) Swing-to gait **50. A client has consumed the following foods during a meal: 5 oz of orange juice; 120 mL of ice cream; 8 oz of milk; 1 cup of tomato soup; 4 oz of pudding. What is the client's intake in mL?** a\) 770 mL\ b) 870 mL\ c) 980 mL\ d) 1,080 mL **51. The nurse is caring for a client with a history of cartilage degeneration caused by osteoarthritis (OA). Which action by the nurse would represent appropriate care for the client?** a\) Observe and prevent pressure on bony prominences.\ b) Provide moist heat compress to the affected extremities.\ c) Provide a cold compress to the affected extremities.\ d) Educate about isometric and isotonic exercises. **52. The nurse is instructing a client with osteoarthritis. Which of the following statements indicates that the client understands these instructions?** a\) \"I will need to lose weight; my doctor says about 20 pounds.\"\ b) \"I should avoid exercise to prevent stressing my joints.\"\ c) \"Increasing my carbohydrate intake will help with joint pain.\"\ d) \"I should limit my water intake to reduce joint swelling.\" **53. What would be the best education to provide for a client on how to prevent accidental poisoning of a child in the home?** a\) Store cleaning liquids in a locked cabinet.\ b) Place medications in a child's reach to encourage independence.\ c) Use child-friendly labels on cleaning liquids for easy identification.\ d) Keep cleaning liquids in a locked cabinet. **54. A nurse is caring for a client with glaucoma and high intraocular pressure. Which pharmacological treatment reduces intraocular pressure?** a\) Adrenergic blocker\ b) Corticosteroids\ c) Prostaglandin analogs\ d) Antihistamines **55. What nursing intervention best decreases a client's susceptibility to infection?** a\) Using standard precautions\ b) Administering prophylactic antibiotics\ c) Restricting visitors in the room\ d) Isolating the client in a negative pressure room **56. The nurse is removing personal protective equipment (PPE). Which item should be removed first?** a\) Gloves\ b) Gown\ c) Face shield\ d) Mask **57. A client with human immune deficiency virus (HIV) has a sudden status change with a large increase in viral load. What action would the nurse take first?** a\) Assess the client for adherence to the drug regimen.\ b) Administer additional HIV medications.\ c) Notify the healthcare provider immediately.\ d) Reassure the client that the viral load will decrease soon. **58. An older adult client tells the nurse that her granddaughter has chickenpox. The client is afraid to visit because she is afraid of getting shingles from her granddaughter. What is the nurse's best response?** a\. \"If you already had chickenpox, you cannot get shingles.\"\ b. \"If you already had shingles, you cannot get them again.\"\ c. \"If you already had chickenpox, you can safely visit your granddaughter.\"\ d. \"Shingles is caused by a different virus than the chickenpox virus.\" **59. Which of the following statements made by a client diagnosed with human immunodeficiency virus (HIV) would require further teaching?** a\) \"I will only need to take HIV medications for 6 months and I will be cured.\"\ b) \"I should continue my HIV medications even if I feel fine.\"\ c) \"It is important to follow up regularly with my healthcare provider.\"\ d) \"I can stop my HIV medications if my viral load is undetectable.\" **60. A nurse is teaching a client who has tuberculosis. What transmission-based precautions should the nurse initiate?** a\) Droplet\ b) Airborne\ c) Contact\ d) Standard **61. What is the priority intervention for the nurse to enhance meeting the psychosocial needs of a client on transmission-based precautions?** a\) Provide the client with diversional activities.\ b) Ensure that the client receives daily visitors.\ c) Discuss the client's treatment plan with the family.\ d) Ensure the client receives daily phone calls from friends. **62. A nurse is advocating for the client while working with the folk medicine practitioner in the best interest of the client. Which action is the nurse demonstrating?** a\) Collaboration\ b) Cultural sensitivity\ c) Cultural competency\ d) Advocacy **63. A client is learning to become a member of the church. Which accurately describes socialization?** a\) Learning behavior, norms, and values\ b) Developing independence and self-sufficiency\ c) Following rigid rules and regulations\ d) Isolating from societal norms **64. A nurse is making sure to not do or say something offensive when providing hygiene care for an Asian client. Which action is the nurse demonstrating?** a\) Cultural awareness\ b) Cultural competence\ c) Cultural safety\ d) Cultural humility **65. Which diagnostic assessment may help determine the presence and degree of central spine involvement in rheumatoid arthritis (RA)?** a\) Arthrocentesis\ b) Bone density scan\ c) Computerized tomography (CT)\ d) X-ray **66. A nurse is in an outpatient clinic collecting data from a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect?** a\) Joint pain at rest\ b) Decreased joint stiffness\ c) Decreased joint swelling\ d) Increased range of motion **67. A client being cared for is blind. What is the best intervention to reduce the risk of the client falling in the hospital room?** a\) Describe the location of objects in the room.\ b) Place a bell on the client's door for alerting staff.\ c) Restrict the client from moving independently in the room.\ d) Keep the room dimly lit to avoid confusion. **68. A nurse is caring for a client complaining of eye dryness. Which interventions should be included in the plan of care?** a\) Assess the client's food choices for vitamin deficiencies.\ b) Administer artificial tears as ordered.\ c) Recommend the client stop wearing contact lenses.\ d) Encourage the client to reduce screen time. **?69. A nurse is educating a client on nutritional needs and preventing cross-contamination. Which statement is an understanding of the education provided?** a\) "I should wash my hands before handling food."\ b) "I should store raw meats on the top shelf of the fridge."\ c) "I can rinse fruits and vegetables with just water, no soap needed."\ d) "I should freeze all leftovers immediately after serving." **70. A nurse is educating a client on carbon monoxide exposure in the home. Which statement indicates an understanding of the educational material provided?** a\) "This toxic gas is colorless and odorless; symptoms can include headache."\ b) "Carbon monoxide exposure can be easily detected by the smell of gas."\ c) "The symptoms of carbon monoxide poisoning are mostly related to dizziness and nausea."\ d) "Carbon monoxide is only dangerous in poorly ventilated spaces like basements." **71. A nurse is educating a client on how to prevent vector-borne pathogens. Which of these should the nurse include in the education?** a\) Combat cross-contamination and cleanliness\ b) Avoid contact with animals that are known to carry diseases\ c) Keep windows open to allow fresh air to flow through the home\ d) Use insect repellent only during the summer months **72. A nurse is working on a medical-surgical unit when a fire alarm is activated. Which intervention would the nurse complete first?** a\) Rescue the clients.\ b) Activate the fire alarm.\ c) Evacuate the building.\ d) Attempt to extinguish the fire. **73. What health promotion must nurses include in clients' education about immunity?** a\) Frequent handwashing\ b) Taking daily vitamins\ c) Staying indoors during flu season\ d) Limiting physical activity during winter **74. Which of these measures is a priority for a nurse to include in caring for a 72-year-old client who just had knee surgery?** a\) Teach the client to use the incentive spirometer.\ b) Provide the client with pain medications as needed.\ c) Encourage the client to perform knee exercises immediately.\ d) Monitor the client's blood pressure frequently. **75. The nurse monitors a client with diarrhea for fluid and electrolyte imbalance. What client manifestation would need further assessment?** a\) Pitting edema\ b) Weight gain\ c) Productive cough\ d) Disorientation **76. A nurse is educating a client on cellular regulation and cancer prevention. Which of the following should the nurse include in the plan of care?** a\) Protect skin with at least SPF 15 to prevent skin cancer.\ b) Minimize exposure to ultraviolet light to prevent skin cancer.\ c) Use other sources of tobacco to prevent oral and lung cancer.\ d) Consume a high-fat low-carbohydrate diet to prevent colon cancer. **77. The nurse noticed the client was exerting effort in breathing, and the client stated that he felt short of breath. What is the first action the nurse initiates?** a\) Raise the head of the bed.\ b) Call the doctor.\ c) Notify the respiratory therapist.\ d) Get a stethoscope to assess the lung sounds. **78. A nurse is caring for a client that has a pelvic fracture. What laboratory test would be the nurse's priority to review?** a\) Hemoglobin and hematocrit (H&H)\ b) Serum calcium levels\ c) Urine specific gravity\ d) Platelet count **79. Which law is the first national legislation to protect privacy for health information?** a\) Health Insurance Portability and Accountability Act (HIPAA)\ b) Affordable Care Act (ACA)\ c) Family and Medical Leave Act (FMLA)\ d) Patient Protection and Affordable Care Act (PPACA) **80. A client who has bone cancer states, "I am in too much pain to walk today." What should the nurse do first?** a\) Inquire about the frequency, quality, and location of the pain.\ b) Administer pain medication as prescribed.\ c) Offer to assist the client with walking.\ d) Encourage the client to take deep breaths to manage pain. **81. The nurse is discharging a Chinese American. Which musculoskeletal disorder education should be included for this ethnic group?** a\) Osteoporosis prevention\ b) Scoliosis screening\ c) Osteoarthritis management\ d) Post-surgical rehabilitation **82. What is the best nursing intervention to implement for a client with limited mobility who cannot move independently?** a\) Passive range of motion\ b) Active range of motion\ c) Encourage ambulation three times a day\ d) Use of mechanical lifting devices **83. A client who has a bunion has been admitted for a bunionectomy. Which intervention should be appropriate for the nurse when preparing the client after the procedure?** a\) Assess the client for valgus in the surgical foot.\ b) Apply cold compresses to the surgical area.\ c) Ensure the client wears a surgical shoe to prevent infection.\ d) Check for signs of deep vein thrombosis (DVT). **84. A nurse is working in a surgical unit. Which of these tasks is appropriate for the nurse to designate to unlicensed assistant personnel (UAP)?** a\) Set up the client's lunch tray.\ b) Administer intravenous medications.\ c) Conduct a preoperative assessment.\ d) Perform a physical exam. **85. What is the priority nursing diagnosis for a client with immobility?** a\) Ineffective breathing pattern related to an inability to breathe deeply in a supine position.\ b) Risk for impaired skin integrity related to prolonged pressure.\ c) Acute pain related to immobility.\ d) Risk for deficient fluid volume related to inability to drink independently. **86. The nurse is caring for a client with hepatitis B and gets stuck with a contaminated needle after administering an injection. Which action should the nurse take first?** a\) Flush the wound and wash with soap and water.\ b) Report the incident to the supervisor.\ c) Obtain a baseline hepatitis B test.\ d) Administer a hepatitis B vaccine immediately. **87. Risk factors can be placed in the following interrelated categories: genetic and physiological factors, age, physical environment, and lifestyle. Which best describes the presence of any of these risk factors?** a\) The chances of getting the disease are increased.\ b) The disease is inevitable.\ c) The person will develop the disease early.\ d) Risk factors do not have an impact on health. **88. The client is a chronic carrier of infection. Which of the following prevents the spread of the infection to other clients and healthcare providers?** a\) Block the portal of exit from the reservoir.\ b) Use antibiotics for prophylaxis.\ c) Administer immunizations to the healthcare team.\ d) Place the client in a positive pressure room. **89. Which of these is the greatest danger to toddlers?** a\) Unattended swimming pool\ b) Electrical cords\ c) Toxic cleaning products\ d) Open windows **90. What physiological factors can influence a client's environmental safety for an elderly client?** a\) Sensory loss\ b) High blood pressure\ c) Obesity\ d) Poor appetite **91. Which of these describes a lifestyle risk factor?** a\) Smoking\ b) Obesity\ c) Genetics\ d) Age **92. The nurse reviews the laboratory blood results. What test result would indicate the presence of infection?** a\) Elevated white blood cell\ b) Decreased platelet count\ c) Low hemoglobin levels\ d) Increased potassium levels **93. How can a nurse promote the prevention of tissue integrity impairment?** a\) Monitor vital signs\ b) Daily weight\ c) Good handwashing techniques\ d) Ensure protein and vitamin C intake **94. Which of the following laboratory results can indicate delayed healing of a client's wound?** a\) Serum albumin 2.9 g/dL\ b) Hemoglobin 14 g/dL\ c) Blood glucose 120 mg/dL\ d) White blood cell count 5,000/mm³ **95. What should the nurse include in the teaching plan for a client scheduled for a punch biopsy?** a\) Local anesthesia will be injected.\ b) You will need to stay overnight in the hospital.\ c) A general anesthetic will be administered.\ d) The biopsy will require stitches for closure. **96. What is the proper method to collect fluid for a viral culture?** a\) Blood sample\ b) Vesicle fluid in a viral culture tube\ c) Nasal swab\ d) Throat culture **97. The client is completing a return demonstration on how to care for hearing aids. What statements by the client indicate the need for further teaching?** a\) "The hearing aids should be cleaned regularly."\ b) "I should store them in a dry place."\ c) "The hearing aids do not need to be cleaned."\ d) "I need to replace the batteries when the sound quality decreases." **98. What should the nurse include when educating the client about a perforated tympanic membrane?** a\) Emergency surgery will be needed to protect your breathing.\ b) Perforated eardrums do not completely heal.\ c) Avoid irrigating the ear canal or getting water in the ear.\ d) Take prescribed antibiotics until you feel better. **99. The nurse is assessing an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous, and the edges of the wound appear to cup in toward the center. Which additional finding would indicate that this is a stage IV pressure ulcer?** a\) The joint capsule of the hip is visible.\ b) The wound is painful when touched.\ c) The edges are irregular and raised.\ d) The area has a small amount of drainage. **100. What nursing intervention is appropriate to improve communication for a client with impaired vision?** a\) Wave your arms when entering the room.\ b) Speak in a louder voice when addressing the client.\ c) Ensure the room is brightly lit at all times.\ d) Describe the location of objects and provide a guide. **101. A nurse is reviewing discharge instructions for a client with myopia. Which nursing response is appropriate to ensure effective communication?** a\) "I will get you glasses, so you are able to read the instructions."\ b) "The instructions are large print. You will not need glasses."\ c) "You can use your cell phone to read the instructions."\ d) "The instructions will be mailed to your home later." **102. A nurse is admitting a client to the medical-surgical unit. Which intervention by the nurse helps to establish a trusting nurse-patient relationship?** a\) Introduce yourself and address the client by name.\ b) Discuss the treatment plan immediately upon arrival.\ c) Use medical terminology to explain the procedures.\ d) Avoid discussing personal details to maintain professional boundaries. **103. Which of the nursing actions is the most important when beginning to develop a therapeutic relationship?** a\) Develop rapport as a basis for ongoing mentoring.\ b) Address all immediate physical needs of the client.\ c) Provide a detailed description of the diagnosis.\ d) Begin treatment protocols right away to ensure client comfort. **104. Which action by the nurse could break trust and weaken the credibility of the nurse in the client's eyes?** a\) Failing to follow up on a client's concern as promised.\ b) Offering extra support when requested by the client.\ c) Discussing the care plan in detail with the client.\ d) Demonstrating active listening during the assessment. **105. The nurse wants to help focus on a conversation about an angry client's feelings to find out what is underneath them. Which of the statements is appropriate?** a\) "I see that you're angry. Can you tell me more about that?"\ b) "You need to calm down before we can talk."\ c) "Anger is not helpful right now, so let's focus on the issue."\ d) "You shouldn't be upset; let's focus on the facts." **106. A nurse is caring for a client that is concerned about an upcoming surgical procedure. Which response by the nurse is best?** a\) "It's normal to be scared. Tell me how you are feeling."\ b) "Don't worry, everything will be fine."\ c) "Most people have no issues with surgery, so you'll be fine."\ d) "Your concern is unnecessary; you have nothing to worry about." **107. A client just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy?** a\) "This must be hard news to hear. Tell me more about it."\ b) "You'll get through this. Don't worry."\ c) "It's important to stay positive and fight the disease."\ d) "We will handle everything; you don't need to worry about it." **108. A nurse is educating a client on nutritional needs and food safety. Which of these best describes how to properly handle food?** a\) Leave cut fresh fruits and vegetables at room temperature.\ b) Store leftovers in the refrigerator for up to a week.\ c) Wash hands and surfaces often while preparing food.\ d) Use expired food products to avoid waste. **109. Which vaccine would require a booster due to an age-related decrease in immunity?** a\) Diphtheria, tetanus, and acellular pertussis (DTaP)\ b) Measles, mumps, and rubella (MMR)\ c) Varicella vaccine\ d) Hepatitis B vaccine **110. A nurse is caring for a client with HIV who is receiving pharmacological treatment to reduce muscle pain. Which medication would the nurse expect in the orders?** a\) Antiretroviral\ b) NSAIDs (Nonsteroidal anti-inflammatory drugs)\ c) Steroids\ d) Muscle relaxants **111. A client with metatarsal bony overgrowth states to the nurse, "My pain occurs when wearing narrow-toe shoes." Which factor is most likely related to the client's statements?** a\) A bunion\ b) Plantar fasciitis\ c) Gout\ d) Hallux rigidus **112. A nurse is caring for a paraplegic client with long-standing mobility problems. Which device should the nurse utilize to increase independence for a client with restricted mobility?** a\) A transfer belt to transfer the client.\ b) A mechanical lift to transfer the client.\ c) A transfer board to transfer the client.\ d) A stand-assistance device to transfer the client. **113. Which of these describes the role of the nurse when communicating with a client?** a\) Encoder\ b) Sender\ c) Prescriber\ d) Receiver **114. A nurse reviews the laboratory results for a patient who was burned 24 hours ago. Which laboratory result would the nurse report to the healthcare provider immediately?** a\) Serum potassium: 6.5 mEq/L (6.5mmol/L)\ b) White blood cell count of 12,000/mm³\ c) Hemoglobin level of 14 g/dL\ d) Blood glucose level of 120 mg/dL **115. What should the nurse include in the discharge teaching for a client after an excisional biopsy for a skin lesion?** a\) Clean the site three times daily after the dressing is removed.\ b) Keep the site covered with a bandage for 1 week.\ c) Avoid applying any ointments to the wound for 24 hours.\ d) Apply an antibiotic ointment to the wound for 5 days. **116. A nurse is caring for a post-operative client following an open reduction internal fixation (ORIF) of a femur fracture. What is included in evaluating the neurovascular status of the client's affected extremity? (Select all that apply)** a\) Color\ b) Temperature\ c) Sensation\ d) Pulse **117. Which of the following statements by a client who has human immunodeficiency virus (HIV) requires further teaching? (Select all that apply)** a\) "I need to ensure that I place my needles in a proper needle disposal container."\ b) "I will monitor my nutrition and fluid status."\ c) "Because I have HIV, that means I'm an AIDS client."\ d) "I can spread this through contact with surfaces, so I need to wear gloves in public."\ e) "I can still have unprotected intercourse with my partner since he doesn't have HIV." **118. The nurse assesses a wound that has exudate. What should be included when documenting the exudate? (Select all that apply)** a\) Amount\ b) Odor\ c) Color\ d) Consistency **119. The Norton Scale is used to measure how much risk a client has of obtaining a pressure ulcer. What is the highest possible score when using this assessment tool?** a\) 20\ b) 25\ c) 30\ d) 15 **120. The admission nurse is completing a Braden Scale Risk Assessment. What potential risk is the nurse assessing?** a\) Pressure ulcer\ b) Respiratory infection\ c) Blood clots\ d) Urinary tract infection **121. A nurse is caring for a client with acute back pain, who states they do not need medication because acupuncture helps relieve their back pain. Which describes these types of therapy?** a\) Integrative therapy\ b) Pharmacological therapy\ c) Complementary therapy\ d) Occupational therapy **122. A nurse is caring for a client with anxiety. Which of these is a nonpharmacologic intervention to manage the client's anxiety?** a\) Application of ice to reduce inflammation\ b) Antianxiety medication to reduce tension\ c) Analgesics to promote relaxation\ d) Aromatherapy to promote relaxation **123. The nurse assesses a deep wound. The area is covered by black necrotic tissue. What term would the nurse use when documenting this wound?** a\) Eschar\ b) Tunneling\ c) Blanching\ d) Cellulitis **124. A client is diagnosed with herpes zoster. Which of the following accurately describes the pharmacological management of herpes zoster?** a\) Only topical medications should be used to treat the condition.\ b) Antivirals should be started within the first 72 hours following eruption.\ c) Vaccination is recommended for those younger than age 60.\ d) Antibiotics can be given either orally or intravenously. **125. Which signs and symptoms would indicate that the client is experiencing a complication from immobility on the musculoskeletal system?** a\) Glucose intolerance\ b) Incontinence\ c) Joint contractures\ d) Decreased peristalsis **126. Which signs and symptoms would indicate that the client is experiencing a complication from immobility on the respiratory system?** a\) Paralytic ileus\ b) Increased circulation\ c) Increased gas exchange\ d) Decreased ventilation **127. Which of these would the nurse include in the plan of care to maximize movement of the joint with independent assistance?** a\) Isokinetic exercises\ b) Isotonic exercises\ c) Active range of motion (AROM)\ d) Passive range of motion (PROM) **128. What diagnostic test is used to detect osteoporosis?** a\) Bone scan\ b) Blood culture\ c) Phalen's maneuver\ d) X-ray **129. A nurse educates a client on medication to increase calcium and vitamin D3 supplementation to a postmenopausal client. Which of the following musculoskeletal disorders is this treatment recommended to promote bone health?** a\) Osteosarcoma\ b) Osteomyelitis\ c) Osteotomies\ d) Osteoporosis **130- A nurse is educating a client about pharmacological treatment for osteomalacia. Which statement by the client indicated the client understands the education?** - **I will take my vitamin D because it is needed for calcium absorption** **131- A nurse is caring for a client with human immune deficiency virus (hiv) that is receiving pharmacological treatment for peripheral neuropathy induced pain. What medication would the nurse expect the provider to have ordered?** a. Acetaminophen b. Pregabalin c. Hydrocodone d. Gabapentin **132- A nurse is caring for a hospitalized client with COVID-19 coronavirus influenza. Which would the nurse expect to administer for artificial passive immunity?** a. Immunoglobulin G (IgG) b. Immunoglobulin M (IgM) c. Convalescent serum d. Diphtheria Tetanus and acellular (DTaP) **133- A client is hospitalized with clostridium(C-difficile). Which medication plates the client at risk for acquiring C- difficile?** a\) Antiviral\ b) Vitamins\ c) Antiemetics\ d) Antibiotics **134. A nurse is educating a client with a multidrug-resistant organism (MDRO) infection. Which of the following is important to include in the discharge education?** a\) Save the remaining antibiotic pills left over\ b) Dispose of unused antibiotic pills\ c) Take all the antibiotics as prescribed\ d) Stop antibiotics after the symptoms improve **135. A client has been taking an integrase inhibitor for human immunodeficiency virus (HIV). Which is an expected side effect of this medication?** a\) Elevated blood glucose levels\ b) Decreased blood pressure and low pulse\ c) Diarrhea, nausea, and abdominal pain\ d) Sore throat, fever, and multiple bruises **136. Which medication would the nurse expect to be ordered for a client with moderate pain who has been diagnosed with human immunodeficiency virus (HIV)?** a\) Oxycodone\ b) Ketoconazole\ c) Acyclovir\ d) Gabapentin **137. The nurse is working with an older adult after a total hip arthroplasty (THA). What consideration is most important with older adults after surgery?** a\) Keep the client's legs abducted with an abduction device\ b) Use a body pillow instead of an abduction device\ c) Encourage the client to be more independent\ d) Encourage use of the incentive spirometer every 6 hours **138. The nurse educated a client in the clinic one week prior to total joint arthroplasty (TJA). What consideration is most important?** a\) Unstable diabetes will be managed and stabilized in surgery\ b) Provide written materials in the appropriate cultural language\ c) Ensure the client signs the surgical informed consent\ d) An active infection elsewhere in the body does not affect the joint **139. Which complication is associated with a lack of or a disruption in the blood supply to the affected bone caused by chronic steroid therapy?** a\) Osteonecrosis\ b) Osteoarthritis\ c) Osteosarcoma\ d) Osteomyelitis **140. An older adult client is returning to the postoperative nursing unit after a hip replacement. What action should the nurse delegate to the unlicensed assistive personnel (UAP)?** a\) Assess the skin under the abduction pillow straps\ b) Apply an abduction pillow to the client's legs\ c) Cleanse and assess the heels for skin breakdown\ d) Monitor cognition to determine when the client can get up **141. What is an early sign and symptom (early disease) of rheumatoid arthritis?** a\) Joint deformity\ b) Moderate joint pain\ c) Morning joint stiffness\ d) Joint inflammation **142. A nurse is discharging a client after arthrocentesis. What statement by the client indicates the client needs further teaching?** a\) "I will notify my healthcare provider about an increase in pain or swelling."\ b) "I will rest and ice the affected joint for 24 hours."\ c) "I will ice for the first 4 hours, then use heat after that."\ d) "I can use acetaminophen for discomfort as prescribed." **143. The nurse is caring for a client on strict bed rest following a surgical procedure. Which of these nursing interventions should the nurse implement in their nursing care?** a\) Assist the client to a high Fowler's position\ b) Ambulate the client to the bathroom\ c) Assess the client for pressure injuries\ d) Instruct the client to turn every 8 hours **144. The nurse encourages a hospitalized client to bring in foods that are appropriate for the client's prescribed diet. Which effects does this have on a client's cultural health practice?** a\) Efficacious\ b) Neutral\ c) Unknown\ d) Dysfunctional **145. Which intervention is the best to prevent an integumentary complication in an immobilized client?** a\) Encourage the client to remain supine\ b) Assist the client with turning every 2 hours\ c) Instruct the client to turn every 12 hours\ d) Educate the client to cough and deep breath **146. The nurse reports that the client has dyspnea when ambulating. How should the nurse document these assessment findings?** a\) Coughing up blood\ b) Shortness of breath\ c) Shallow respirations\ d) Wheezing 147\. a nurse is assessing client on strict bed for one week. Which of the following finding should the nurse identify as an indication that the client ready to ambulate? a\) performs active range of motion (ROM) exercises of all extremities b\) needs assistance raising her legs to put on socks. c\) develops fatigue when assisting with morning hygiene care. d\) demonstrates labored breathing when eating breakfast. 148\. a nurse is caring for a client who cannot bear wiight on their fractured ankle with cast. Which intervention is appropriate? \- Educated the client to walk with three-point gait. 149\. A nurse is proving discharge teaching to a client who has a fracture of the right tibia a fiberglass cast. Which of the following instruction should the nurse include in the teachin? \- do not weight bear until there is evidence bone healing 150\. What is the proper technique for assessing an adult client's ear with an otoscope? \- Pull the pinna up and back with the nondominant hand \\