NUR 2032 FINAL EXAM CARE MANAGEMENT EVOLVE

NUR 2032 FINAL EXAM CARE MANAGEMENT EVOLVE Chapter one Evolve 1. Which important aspect of coordinating care within the interdisciplinary team is facilitated by use of the “SBAR” and “PACE” procedures? a. Communication b. Implementation c. Policymaking d. Protocol development 2. The nurse educator is instructing newly hired registered nurses about patient-centered care. Which competency categories are included in this content? a. Attitudes b. Environments c. Judgements d. Knowledge e. Skills f. Values 3. Bedside computers are an example of informatics used in health care primarily for which purpose? a. Documenting interdisciplinary care b. Enhancing collaboration and coordination of care c. Offering client access to e-mail and the internet d. Retrieving data from evidence-based practice 4. The nurse has recently been assigned to a medical-surgical clinical rotation. According to the scope of medical-surgical nursing, what type of client assignment does the nurse expect to see? a. Hospitalized children with acute and chronic illnesses b. Hospitalized adults with acute and chronic illnesses c. Older adult in a nursing home d. Working adults in a corporate setting 5. Which of these hospital staff members will the nurse manager assign to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury? a. The nurse responsible for the client’s case management b. The physical therapist who developed the client’s exercise program c. The health care provider assigned as the client’s medial resident d. The unit-based RN who has cared for the client during the hospital stay 6. The nurse is asked to collaborate with other to implement an interdisciplinary plan of care for a client. Which health care team members are essential for the client’s daily care regimen? a. Anesthesiologist b. Case manager c. Health care provider d. Occupational therapist e. Chaplain 7. Which principal nursing action best support a focus on client safety? a. Client restraints b. Handwashing c. Preoperative checklist d. Respect of others e. Five rights of drug administration 8. The nurse is appointed to a hospital committee whose goal is to “improve the safety of nursing practice.” Which areas of practice are included in the committee’s task? a. Attentiveness/surveillance of client b. Mandatory reporting c. Medication administration d. Participation in professional organizations e. Prevention of errors or complications f. Teaching clients about the care regimens 9. An older client who has had a total hip replacement will be transferred to rehabilitation center for continuing care before going home the joint commission, along with national patient safety goal standards, mandates communication between hospital nurses and other providers to ensure adequate transition management. Which aspects of this client’s care plan are most important for the nurse to communicate to the rehabilitation center care team? a. Third-party payer information b. Pain medication needs c. Primary care provider d. Medical history of osteoarthritis 10. The nurse supports the client and family in deciding on the “Do Not Resuscitate” order. Which ethical principle that guides nursing clinical decision making is demonstrated in this situation? a. Beneficence b. Justice c. Legality d. Self-determination 11. The nursing student asks the supervising nurse whether a certain fall protocol used on the nursing unit is effective. To demonstrate effectiveness, what does the supervising nurse identify? a. Information about how to implement a fall protocol and what nurses need to document b. Data about the number of falls after the protocol was introduced compared with previous fall rates c. The number of clients who currently have a fall protocol in place d. National statistics about the use of fall protocols to prevent serious injury from falls 12. A previously stable postoperative client on the medical-surgical unite now has a blood pressure of 88/40 mm Hg and a heart rate of 124 beats/min. after placing the client in Trendelenburg position, which action does the nurse perform next? a. Activate the rapid response team b. Call for a code blue c. Determine the cause of the changes d. Re-check the vital signs in 5 minutes 13. When developing a standardized plan of care for clients with a diagnosis of pneumonia, how does the nurse find the best information about providing optimal nursing care? a. Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia b. Research the most recent articles in nursing magazines that discuss care for clients with pneumonia c. Review the chart to determine what primary health care provider’s prescriptions are frequently written for clients with pneumonia. d. Survey experienced RNs about which nursing action effective when caring for clients with pneumonia. 14. Which nursing activity is best for the charge nurse on the medical-surgical unit to delegate to staff members who are unlicensed assistive personnel (UPAs)? a. Feeding a client whose hands are affect by rheumatoid arthritis b. Increasing the oxygen flow rate for a client who has wheezes c. Position a client who has just returned from hip surgery d. Taking vital signs for a client who is having acute chest pain 15. Which nursing action demonstrates use of the principle of justice? a. A 32-year-old client is prevented from falling during the initial postoperative period following her hysterectomy b. A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer c. An 82-year-old client is provided access to the hospital patient advocate for processing of a compliant d. The parent of a 13-year-old are included in discussion about the course of their teen’s treatment and care. 16. Which role of the medical-surgical nurse is demonstrated when writing a plan of care for a client who is newly admitted to the hospital? a. Advocate b. Caregiver c. Communicator d. Educator 17. When transferring a client who was admitted with chest pain from the emergency department (ED), which information is essential for the ED nurse to communicate to the nurse on the medical-surgical unite? Select all that apply a. The client is being admitted for ongoing monitoring of pain and vital signs b. The client has private insurance and is also covered by Medicare c. Nitroglycerin and morphine sulfate were given to relieve the pain d. Frequent reassurance is needed because the client has a high anxiety level e. The client has a family history of heart disease and hypertension f. A coronary arteriogram should be scheduled as soon as possible 18. Which action does the nurse take first when preparing to do discharge teaching for a 73-year-old client who is being discharged after prostate surgery? a. Ask what the client knows about self-care after prostate surgery b. Have family members available during the teaching c. Provide written information about post discharge care d. Plan to teach early in the morning after the client has eaten. 19. The nurse is working in the intensive care unite. When does the nurse call the rapid response team (RRT)? a. An 87-year old client awakens confused, then reorients quickly b. A newly admitted client request pain medication c. A postoperative client’s dressing has bloody drainage d. A postoperative client’s blood pressure suddenly drops 20. The nursing student has been assigned to the hospital rapid response team (RRT). Which statement by the student indicates a correct understanding of the RRT member’s purpose? a. I will be caring for clients in the hospital b. I will be riding along in the hospital’s ambulance c. I will be admitting clients to the hospital d. I will be participating in code blude resuscitation Chapter two Evolve 1. The nurse is teaching a health and wellness class at a local senior citizen center. When discussing methods to promote cognition, which options should be included? a. Play card games b. Take music lessons c. Read the newspaper d. Learn a new language e. Complete crossword puzzles 2. The nurse cares for a client that is immobile. The client is most at risk of develop which complication? a. Diarrhea b. Renal calculi c. Hypertension d. Muscle hypertrophy 3. The nurse cares for a client reporting moderate pain. Which nursing action is MOST important to provide the client effective pain relief? a. Teach the client about pain b. Establish a trusting relationship c. Provide alternative measure to relieve pain d. Determine how various relaxation techniques affect the pain 4. The nurse evaluates a client’s fluid balance. Which finding most likely requires an intervention? a. Output is equal to intake b. Output of1500mL in 24 hours c. Output 200 mL more than intake d. Output 700 ml less than intake 5. The nurse cares for a client diagnosed with polycythemia. What should the nurse include in the client teaching? a. Watch for excessive bruising b. Avoid crowds and people who are ill c. Report any pain, redness, or swelling in calves d. Do not take nonsteroidal anti-inflammatory (NSAIDs) medications 6. The nurse on a medical unit just received report. Which client should the nrue anticipate on order for arterial blood gases? a. Admitted with chronic pancreatitis b. Admitted for excessive salicylate ingestion c. History of type 2 diabetes with a blood glucose of 180 mg/dL (10 mmol/L) d. History of chronic obstructive lung disease, respiratory rate 20, O2 93 on room air 7. The nurse prepares a presentation on healthy defecation for health fair. Which information should the nurse include when discussing constipation? Select all that apply a. Do not ignore the urge to defecate b. Establish a regular exercise routine c. Decrease the amount of fiber in diet d. Maintain fluid intake of at least 2000 mL/day e. Increase the amount of fresh fruits and vegetables in diet f. Use over the counter constipation medication frequently 8. The nurse obtains the health history of a client admitted to the hospital with difficulty breathing and chronic obstructive pulmonary disease (COPD). Which factors from the client’s history are related to developing COPD? Select all that apply a. Has history of asthma b. Drinks six cans of beer a day c. Had two myocardial infarctions (MIs) d. Worked as a coal miner for 20 years e. Works on a grain farm for last 8 years f. Smoked ½ pack of cigarettes per day for 30 years 9. The nurse is teaching a health and wellness class. What will the nurse include in the discussion of common risk factors for impaired cellular regulation? select all that apply a. Smoking b. Poor nutrition c. Drinking alcohol d. Physical inactivity e. Over the age of 70 10. The nurse cares for a client diagnosed with bowel and bladder incontinence. Which is a priority nursing diagnosis for this client? a. Imbalanced nutrition b. Impaired skin integrity c. Decreased fluid volume d. Altered level of consciousness Chapter 3 evolve 1. The RN has delegated nursing actions to experienced unlicensed assistive personnel (UAP) working in a long-term care facility. Which action require direct supervision by the RN? Select all that apply a. Assisting a 70-year-old client who has new-onset leg pain when ambulating b. Feeding an 82-year-old client who has severe joint disease in both hands c. Helping a 66-year-old client complete her personal hygiene d. Repositioning a 69-year-old client who has recently became unconscious e. Assisting a 72-year-old client who has chronic arthritis of the knee to the restroom 2. The RN manager of a skilled nursing facility wants to assign a staff member to assess the nutritional needs of an emaciated client with pressure ulcers. Which of these team members is appropriate? a. The LPN/LVN treatment nurse responsible for the client’s wound care b. The LPN/LVN medication nurse for this client c. The nurse assistant caring for this client for the past 2 weeks d. The RN team leader responsible for care planning 3. The nurse is conducting a medication assessment on an older adult client who is being admitted to a long-term care facility for rehabilitation following a hip replacement. With Beers criteria used as a resource, which drug poses a potential risk for this client? a. Acetaminophen (Tylenol) b. Celecoxib (Celebrex) c. Digoxin (Lanoxin) d. Mesalamine (Asacol) 4. The RN at a skilled nursing facility is supervising a staff of LPN/LVNs and nursing assistants. Which of these nursing actions does the RN delegate to a nursing assistant? a. Admitting a new client with multiple bruises over the upper thighs b. Assisting a client with chronic joint stiffness to ambulate c. Making hourly assessments on a client with delirium and dementia d. Monitoring a confused client who has been placed in a jacket restraint 5. The nurse is assessing an older adult client’s alcohol use. Which client statement warrants a follow-up collection of more data? a. I am a “teetotaler”; I never drink anything alcoholic b. I had three glasses of champagne at my granddaughter’s wedding last month c. I like to have a glass of wine every once in a while d. I usually drink two vodkas to help me get to sleep each night 6. Which is the fastest-growing subgroup of older adults? a. Young old b. Middle old c. Old old d. Elite old 7. A 70-year-old client whose spouse died the previous year says to the nurse “life is not fun anymore.” How does the nurse respond? a. Are you getting enough sleep? That makes me feel better b. Tell me about your support network, such as friends and family c. How are you feeling about death of your spouse after this length of time? d. Why don’t you go on a vacation? A change of scenery will do you good 8. Which older adult client’s living situation typically presents highest risk for abuse? a. At home alone b. At home with a spouse c. In a long-term care facility d. With adult daughter and grandchildren 9. The RN is arriving for night duty at an acute care hospital. Which client does the RN assess first? a. A 65-year-old scheduled for next-day surgery b. A 68-year-old with chronic protein-calorie malnutrition c. A 70-year-old with a history of gout and joint pain d. A 72-year-old admitted with postoperative delirium 10. The nurse is assessing the nutritional status of an older adult client. Which statement made by the client needs to be explored further? a. Although I enjoy eating sweets and desserts, I need to balance them with heathier foods b. For protein in my diet, I like to get the fish sandwich and first at the fast food drive through at least 3 times a week c. To keep my bowel movement regular, I try to eat some fresh fruits and vegetables each day d. With less activity and exercise in my life these days, I should reduce my total calorie intake 11. An older adult client who lives with her daughter is admitted to the hospital. During the admission assessment, the nurse notes strong body odor, several large pressure ulcers, and limb contractures. What does the nurse do first? a. Ask the daughter about the ulcers and contractures b. Contact the hospital social worker c. Gives the client a bath d. Notifies the health care provider 12. The nurse is teaching a class of older adults about ways to promote their cognitive health. Which collaborative intervention will be most helpful for them? Select all that apply a. Allowing for increased rest and relaxation time b. Having solitary time to reminisce about life experiences c. Joining a peer group with a common learning goal d. Learning a new skill e. Meditating for 30 minutes each day f. Starting a new physical activity 13. The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is most important in promoting health and safety? a. Continue to eat healthy foods, especially protein b. Seek counseling for depression because it is not a normal part of aging c. Enroll in a safe driving refresher course and avoid risky diving situations d. Walk 30 minutes three to five times a week 14. At a follow-up home-care visit after repair of a fractured radial bone, an older adult client states “I am not sleeping at all during the night.” The client partner reports that the client is sleeping all day. Which intervention does the nurse suggest? a. Increasing the client’s daytime activities b. Placing a “Do not disturb” sign on the door a night c. Taking additional pain medication (analgesic) during the day d. Taking herbal remedies to enhance the effects of prescribed medication 15. A client with end-stage lung cancer and metastasis to the brain has been admitted to the medicalsurgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. Which nursing intervention is required for this client? a. Checking the restraints every 1 to 2 hours b. Releasing the restraints at least every 2 hours c. Using chemical sedation instead of restraints d. Using the most restrictive devices to prevent falls 16. An 80-year-old client is being relocated from home setting to a long-term care facility. Which nursing intervention best minimizes the effects of relocation stress syndrome? a. Explaining all procedures and routines to the client’s family at the time of relocation b. Keeping the room clear of personal belongings to reduce the risk of falling c. Providing the client with limited decision making to avoid stressful situations d. Reorienting the client frequently to his or her new location 17. A 70-year-old man who recently lost his spouse reports feeling lonely and sad much of the time. He lives alone and has no identified health problems, but reports “not feeling well” on most days. What will the nurse assess first to help prevent problems associated with client’s situation? a. The availability of activities for senior citizens b. Physical strength and ability to exercise c. Spending sprees on unnecessary items d. Food intake and recent weight changes 18. The home health aide reports that a 70-year-old client is noncompliant in taking prescribed medications. What does the nurse do to solve this problem? a. Asks what the barriers are to taking the medications b. Color-code the labels or place dots on the bottles c. Provides a weekly pill box with daily compartments d. Provides medications with bottle caps that are easy to open 19. A 72-year-old client admitted to the hospital for congestive heart failure has a history of a fracture hip due to a previous fall. The client is taking oxycodone-acetaminophen (Tylox) as needed for pain secondary to recent dental procedure. Which risk factor puts this client at greatest risk for a fall? a. Age b. Diagnosis c. History of fall d. Narcotic use 20. The nurse is teaching a class of unlicensed assistive personnel (UAP) about turning and repositioning clients in a long-term care setting. Which client requires extreme caution and is at greatest risk for a skin tear? a. A 38-year-old client with paraplegia resulting from a motor vehicle accident b. A 70-year-old client with a recent total hip replacement receiving rehabilitation care c. An 80-year-old client with a recent stroke and left-sided paralysis d. An 85-year-old client with breathing problems receiving daily doses of prednisone 21. The nurse is completing a hospital admission assessment on an 86-year-old client with renal impairment. The client’s daughter gives the nurse a long list of drugs that the client is taking at home, both prescriptions an over-the counter. What does the nurse do next? a. Calls the pharmacy to verify that the drugs do not interact adversely b. Calls the health care provider to verify the drug list c. Copies the list to the assessment data form d. Ensure that all the drugs have been ordered for the client’s hospital stay 22. The son of an older adult client states that he has noticed progressive periods of forgetfulness in his father over the past year. After noting the son’s comments and assessing the client, which cognitive problem does the nurse suspect the client may have? a. Drug adverse effects b. Delirium c. Dementia d. Depression 23. An older adult client who is admitted to the medical-surgical unit with a diagnosis of heart failure states to the nurse, “I am of no use to anyone. I just want to die.” What therapy does the nurse expect the provider to order to ensure this client’s safety? a. Treatment with a tricyclic antidepressant medication b. Encouraging the client to rest. He or she may feel better in the morning. c. Obtaining a social work consultation to evaluate the client’s family situation d. Using a selective serotonin reuptake inhibitor to manage depression Chapter 6 evolve 1. The nurse is reinforcing the physical therapist’s teaching on gait training for a client who had a total knee replacement 6 weeks ago. Which ambulatory aid does the nurse expect the client to be using? a. Crutches b. Straight cane c. Walker with a built-in seat d. Walker with rollers 2. A paraplegic client is being discharge home from rehabilitation. What primary concerns does the nurse include in the client’s discharge plan? Select all that apply a. Assistive and adaptive devices b. Cast care c. Depression prevention d. Range-of-motion (ROM) exercises e. Wheelchair accessibility 3. The nurse has been effectively using digital stimulation in older adult clients with constipation problems. For which client is this practice unsafe? a. A 68-year old with long history of multiple sclerosis (MS) b. A 70-year-old with recently diagnosed atrial fibrillation c. A 74-year-old who is 4 months post cerebral vascular accident (CVA) with left-side weakness d. An 84-year-old with progressive dementia and confusion 4. A nursing assistant asks the rehabilitation nurse for assistance in transferring a 320-pound (145 kg) client from the bed to a wheelchair. How does the nurse respond? a. First, I want to check the physical therapy care plan b. Ok, but let’s get the mechanical lift device c. Sure, but we need to ask additional staff members for assistances d. Yes, I would be happy to help you transfer the client 5. The medical-surgical nurse is coordinating transfer from acute care to community-based care for a client who requires rehabilitation. Which interdisciplinary team members will be the primary decision makers in this transition? a. Case managers b. Client and family c. Medical-surgical nurses d. Rehabilitation nurses 6. An 82-year-old client is being discharged after successful bladder and bowel training. Before going home, the client ask what food can be eaten to prevent constipation. What is the best response by the nurse? a. Continue on a soft diet b. Decrease your fluid intake c. Eat at least 2 slices of whole wheat bread daily d. Increase your fiber intake with fruits, vegetables, beans, and unsalted nuts 7. A client has been hospitalized with a non-life-threatening C-spine neck injury. The interdisciplinary rehabilitation team has worked with the quadriplegic client for 4 months. Which outcome indicates that the team’s efforts are effective? a. Constipation now occurs only 3 days a week b. Mobility requires multiple assistive devices c. Personal care is performed with help from the family d. Skin is intact, with no evidence of skin impairment 8. A client has just received a bisacodyl (Dulcolax) suppository. How soon after administration does the nurse expect results to be evident? a. 5 to 10 minutes b. 10 to 15 minutes c. 15 to 30 minutes d. 30 to 45 minutes 9. A client in rehabilitation says “this is too hard. My life will never be the same again!” what is the nurse’s BEST response? a. How did you handle challenges before you were injured? b. Should I call a family member to help c. Why don’t you try a relaxation exercise d. You will be fine, don’t worry so much 10. The client is struggling with use of eating utensils. Which rehabilitation team member is brought in to help the client with this problem? a. Activity therapist b. Occupational therapist c. Physiatrist d. Physical therapist 11. An 80-year-old client is bedridden after having a cerebral vascular accident. Which nursing intervention does the nurse use to help prevent skin breakdown? a. Applying moist packs to the skin every shift b. Ensuring the client’s skin remains dry and clean c. Decreasing calories consumed, avoiding weight gain d. Turning and repositioning at least every 4 hours 12. An 82-year-old client with medication-controlled hypertension has altered bladder and bowel patterns as a result of an uninhibited bowel and bladder. Bowel training has been unsuccessful despite consistent toileting and dietary modifications. Why is bisacodyl (Dulcolax) prescribed for this client? Select all that apply a. For its action as an effective bladder antispasmodic b. To promote bladder emptying c. To enhance the action of prescribed antihypertensive medication d. To effectively reestablish defecation patterns e. To promote rectal emptying 13. The partner of a newly diagnosed paraplegic client says, “I don’t know how I am going to manage a job, car for my partner, and take care of the family.” How does the nurse respond? a. Can you quit your job? b. How did you handle challenges before your partner was injured? c. Let’s see what resources are available to help d. Things will get better and you will be fine 14. A rehabilitation nurse is teaching the client with a spastic bladder to perform intermittent catheterizations. Which client statement shows the need for further education? a. Before I catharize myself, I will try to urinate b. I can wait from 9 AM until 6 PM between catheterizations c. I will use the Valsalva and Crede maneuvers before trying to urinate d. You can teach my son to help me with my catheterizations 15. The rehabilitation nurse in a medical-surgical setting is assessing the client’s ability to perform activities of daily living (ADLs). Which test does the nurse use? a. Confusion assessment method (CAM) b. Functional independence measures c. Minimum data set d. Shift change assessment 16. A paraplegic client with injury to the sixth thoracic vertebra has urinary incontinence that is assessed as “sudden and gushing.” When catheterized after being incontinent, urine remains in the client’s bladder. Which bladder training technique does the nurse recommend for this client? a. Providing a high-fiber diet b. Scheduling intermittent catheterizations c. Taking an antispasmodic medication as prescribed d. Using the Valsalva and Crede maneuvers 17. Which nursing intervention does the rehabilitation nurse delegte to the nursing assistant who is caring for a 70-year-old client with ride-side weakness following a stroke? a. Arrange for family members to participate in planning for discharge b. Determine whether the client’s passive range-of-motion (ROM) exercises should be increased c. Reinforce the client’s placing the right arm in the sleeve first when dressing d. Teaching the client to use an extended shoehorn when putting on shoes 18. What role does the rehabilitation nurse have in the functioning of the rehabilitation team? Select all that apply. a. Coordinates holistic care b. Coordinates rehabilitation team activities c. Develop the client’s fine motor skills d. Plans continuity of care for discharge e. Retrains clients with swallowing challenges 19. A rehabilitation client is being discharged home. Which nursing intervention provides the best assessment for home modifications, while helping diminish the client’s anxiety about the process of discharge? a. Doing discharge teaching b. Having a home visit made by the case manager c. Making a leave of absence (LOA) visit possible d. Performing a pre-discharge assessment 20. An 82-year-old woman is admitted to the transitional care unit for stroke rehabilitation with a history of uncontrolled hypertension, coronary artery disease, and elevated cholesterol levels. Her blood pressure (BP) is currently controlled with antihypertensive medications. The UAP reports that the client’s systolic blood pressure drops by 20 mm Hg when the client gets out of bed. What is the likely cause of this client’s change in blood pressure? a. Her stroke is worsening, becoming more acute b. Orthostatic hypotension is exacerbated by antihypertensive medication c. The dose of her antihypertensive medication is to high d. The does of her antihypertensive medication is to low 21. A client has a priority problem of skin breakdown related to immobility and incontinence. Which nursing intervention does the rehabilitation RN delegate to a nursing assistant? a. Assessing the client’s skin for areas of breakdown b. Developing a schedule for turning the client c. Planning a diet high in protein and calories d. Re-positioning the client every 2 hours 22. The nurse is mentoring a nursing student about best practices for safe client handling. What practice does the nurse teach the student? a. Keep the client at arm’s length to maximize your leverage in moving him or her b. Place your feet at right angles to the client’s feet to stabilize yourself c. Put the bed at waist level for care and hip level for movement of the client d. Try to keep the client positioned to your side so that you can benefit from a rotating motion when moving him or her 23. The hospital nurse is assigned to establish a rehabilitation milieu on the unit. What elements does the nurse include? Select all that apply a. Allowing time for clients to practice self-management skills b. Encouraging clients and providing emotional support c. Keeping to a structured hospital schedule (e.g., medication administration) d. Making the inpatient unit a more homelike environment e. Carefully monitoring fluid and dietary intake f. Protecting clients from embarrassment (e.g., bowel training) 24. Following a fall, a 62-year-old client is admitted to the rehabilitation unit with a broken collarbone and a full leg brace. Which transfer technique is indicated for this client? a. Bear-hug technique b. Cane-assisted transfer c. Mechanical lift d. Slide board 25. Following a cerebral vascular accident, a client with right-sided hemiplegia is in a rehabilitation unit. Which nursing intervention is effective in promoting the client’s independence? a. Assisting the client with all of his or her activities of daily living (ADLs) b. Instructing the client step-by-step on how to put on his or her robe c. Telling the client to the best that he or she can do d. Sending the client to a long-term care facility 26. Which staff member does the manager of an inpatient rehabilitation unit assign as the case manager for a stroke client with physical and speech deficits? a. Physical therapist b. Recreational therapist c. Rehabilitation nurse d. Speech-language pathologist 27. A client with lower motor neuron spinal cord dysfunction has not voided, and a bladder scan shows 700 mL of urine in the bladder. Using the client’s bladder training plan ,what action does the staff RN advise a new graduate nurse to take first with this client? a. Administer a dose of oxybutynin chloride (Ditropan) b. Insert a straight catheter to empty the bladder c. Reassess the client’s bladder volume in 2 hours d. Remind the client to try the Valsalva maneuver 28. A client with a traumatic brain injury is admitted to the rehabilitation unit. Which rehabilitation team member does the nurse assign to develop the plan to improve the client’s ability to bathe and dress independently? a. Activity therapist b. Cognitive therapist c. Occupational therapist d. Physical therapist 29. Which client does the RN in the rehabilitation unit plan to assess first? a. A 45-year-old with multiple sclerosis (MS) who reports constipation b. A 56-year old with a spinal cord injury and new onset redness over the sacral area c. A 63-year-old who has had a myocardial infarction (MI) and is expressing anxiety about walking d. A 70-year-old with a joint replacement who needs to be medicated before exercising 30. A client with ride-sided weakness is receiving antihypertensive medication. What does the RN communicate to the physical therapist (PT), who is planning to help the client walk? a. Monitor the client for weakness and fatigue during exercise b. Move the client for lying to standing slowly c. Remind the client to use the left side to grip d. Use a gait belt when ambulating the client 31. A recently injured paraplegic client is in rehabilitation. Which client comment indicates that he or she is adapting to new self-care activities? a. I am so tired today, I want to rest b. I do not want to do this today c. My dog can do this—why can’t I do it too? d. This is not working; I need to try something else Chapter 7 evolve 1. A hospitalized client of the Islamic (Muslim) religion is dying. What concept does the nurse share with the health care team about this client’s beliefs about death? a. Death is seen as the beginning of a new and better life, with Islam as the vehicle. b. Life experiences do not affect the individuals preparation for everlasting life c. The timing of death is under the power of the person who is facing death 2. Which condition, when assessed in the dying client, requires that the nurse take action? a. Alternating apnea and rapid breathing b. Anorexia c. Cool extremities d. Moaning 3. A client with terminal lung cancer is receiving hospice care at home. Which nursing action does the RN manager ask the LPN/LVN to do? a. Administer prescribed medications to relieve the client’s pain, shortness of breath, and nausea b. Clarify family members feelings about the meaning of client behavior and symptoms c. Develop a plan of care after assessing the needs and feelings of both the client and the family d. Teach the family to recognize signs of client discomfort such as restlessness or grimacing 4. A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention does the nurse implement? a. Brings in the client’s favorite food b. Calls the family to come in right away c. Gives intravenous hydration d. Offer ice chips 5. In a dying client’s hospital room, the nurse overhears family telling the client to “calm down”, and observes the client being agitated and making repetitive motions. What action does the nurse take? a. Askes the family to speak in low tones or whisper to avoid disturbing the client b. Offer to call and have a hospital chaplain come to help the client calm down c. Recommends giving the client antianxiety medication to reduce distress d. Suggest that the family tell the client that things are “all right” 6. The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client’s life? a. Do you believe in God? b. Tell me about the history of religion in your life c. What give you purpose and meaning in your life? d. Where have you been attending church for the past several years? 7. A client admitted with non-life-threatening illness says “I was asked to fill out an advance directive when I was admitted, but I was too stressed. What was it all about?” how does the nurse respond? a. Advance directives are only for those individuals who are severely ill b. Advance directives allow a client to convey his or her wishes about health care ahead of time c. Most Americans have an advance directive in place; you will need to see a lawyer d. You should have completed the paperwork before you were admitted 8. A dying client exhibits signs of agitation. The foley catheter has drained 100 mL in the last 3 hours, and the client’s last bowel movement was yesterday evening. What does the nurse do first? a. Administer an analgesic b. Arrange for a consultation with a bereavement counselor c. Assess the client for impaction d. Change the foley catheter to ensure adequate drainage 9. The nurse is coordinating interdisciplinary palliative care interventions for the dying client. Which goal is the nurse seeking to meet? a. Avoiding symptoms of client distress b. Ensuring an expedited death c. Meeting all of the client’s needs d. Facilitating a peaceful death for the client 10. The daughter of a dying client says, “I don’t want my father to be uncomfortable.” How does the nurse respond? a. Do you want to talk to the bereavement nurse? b. Your father will be closely monitored and cared for c. Your father will be kept sedated d. We will send him to hospice when the time comes 11. The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? a. A 26-year-old with metastatic breast cancer who is experiencing pain related at 10 (0-to10 scale) and anxiety b. A 30-year-old with AIDS-associated dementia and agitation who is asking for assistance with calling family members c. A 62-year-old with lung cancer who has cool, clammy, dusky skin, and blood pressure of 64/20 mm Hg d. A 70-year-old with cancer of the colon who has a respiratory rate of 8 with loud, wetsounding respirations 12. A hospice client has just died. Which of these postmortem nursing tasks is most appropriate to delegate to a nursing assistant? a. Assessing the client for cessation of respiratory effort and lack of pulse b. Documenting the time of death and required assessment data on the chart c. Notifying the spouse and other family members about the client’s death d. Removing all IV lines or tubes according to the hospice policy 13. The family of an unconscious dying client realizes that their mother will die soon. The client’s children are having a difficult time letting go. How does the nurse respond to the needs of this family? a. “don’t be upset; she wouldn’t want it that way.” b. She will soon be in a better place.” c. “things will be fine, try not to worry so much.” d. “this must be difficult for you.” 14. The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the nursing assistant to visit? a. Advanced cirrhosis of the liver and just called the hospice agency reporting nausea b. Aggressive brain tumor and needs daily assistance with ambulation and bathing c. Inoperable lung cancer and considering whether to have radiation and chemotherapy d. Prostate cancer and bone metastases and how new-onset leg weakness and tingling 15. A hospice client becomes to weak to swallow. What does the nurse do initially to increase the client’s comfort? a. Administer nutrition and fluids though a nasogastric tube b. Explains to the family that aspiration may be a concern c. Obtains a physician order to initiate an IV line d. Teachers the family how to provider oral care 16. A dying client says to the nurse “I am afraid to die. I did a lot of wrong things in my life.” How does the nurse respond? a. “don’t worry, God will forgive you.” b. “I’m sure it is nothing to worry about.” c. Tell me more about that d. Why? What did you do wrong? 17. A client diagnosed with lung cancer 6 months ago is now ventilator-dependent and unresponsive. The family wants to remove the ventilator and stop antibiotics and IV fluids. What does the nurse do next? a. Facilitates a meeting between the family and health care team b. Removes the interventions, per the family’s wishes c. Tells the family that removing the interventions is illegal d. Waits to obtain information on the client’s wishes 18. A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order does the nurse implement first? a. Albuterol (Proventil) 0.5% solution per nebulizer b. Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed c. Oxygen 2 to 6 L/min per nasal cannula d. Prednisone (deltasone) elixir 10 mg orally 19. In which newly admitted client situation does the nurse initiate a conversation about advance directives? Select all that apply a. A client with a non-life-threatening illness b. A person who currently has advance directives c. The client with end-stage kidney disease d. The comatose client who was injured in an automobile crash e. The laboring mother expecting her first child 20. A Christian client is struggling with a diagnosis of cancer and says “why is life so unfair?” what health care team member does the nurse ask to provide support? a. Client’s family b. Physician c. Hospital chaplain d. Psychiatrist 21. A dying client is having difficulty swallowing oral medications. Which intervention does the nurse implement for this client? a. Asks the pharmacy to substitute intramuscular (IM) equivalents for the medications b. Asks the provider if the medications can be discontinued or substituted c. Crushes the pills, open the sustained-release capsules, and mixes them with a spoonful of applesauce d. Does not give the medication and documents: “unable to swallow” 22. A client has died after a long hospital stay. The family was present at the time of the client’s death. Which postmortem action does the nurse implement? a. Asks the family if they wish to help wash the client b. Asks the family to leave during post-death care c. Raises the head of the bed and opens the client’s eyes d. Removes dentures and any prosthetics 23. A dying client cannot swallow and is accumulating audible mucus in the upper airway (Death rattles). The nursing assistant reports that these noises are upsetting to the family members. What does the nurse tell the assistant to do? a. Assist the family in leaving the room so that they can compose themselves b. Place the client in a side-lying position so secretion can drain c. Position the client in a high-fowler’s position to minimize secretions d. Use a Yankauer suction tip to remove secretion from the client’s upper airway 24. The nurse recognizes signs and symptoms of delirium in an 80-year-old client who is dying from metastatic breast cancer. What does the nurse do initially for this client? a. Requests an order for an antipsychotic medication to control these symptoms b. Collaborates with the end-of-life (EOL) care team to evaluate possible medicationinduced causes c. Discontinues all medications that have central nervous system adverse effects d. Assures the client’s family that this terminal delirium indicates that death is imminent 25. A client dying of cancer is receiving high doses of opioids. In addition, which intervention is the most effective for this client? a. Classical music b. Deep muscle massage c. More pain medication d. Short, light massage 26. A nurse who is skilled in complementary and alternative medicine (CAM) therapies works on a cancer unit with clients who are terminally ill. For which client symptoms does the nurse use these therapies? a. Constipation b. Cool extremities c. Increased pain d. Memory loss Chapter 14 1. The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of the Joint Commission National Patient Safety Goals (NPSG), what will the nurse be required to do? a. Ensure that the correct procedure is noted in the client’s history b. Remind the surgeon that the client will have a left knee arthroscopy c. Verify with the client that a left knee arthroscopy will be performed. d. Mark the left knee site with the client awake and the surgeon present 2. A preoperative client smokes a pack of cigarettes a day. What is the nurse’s teaching priority for the best physical outcomes? a. Instruct the client to quit smoking b. Teach about the dangers of tobacco c. Teach the importance of incentive spirometry d. Tell the client that smoking increases postoperative complications 3. The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instructions? a. “I will wake up with a tube in my throat” b. “I will have a bandage on my chest” c. “My family will not be able to see me right away” d. “Pain medication will take away my pain” 4. Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? a. Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. b. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer c. Obtain the medical history from a client who is scheduled for a total hip replacement d. Assess the client who is being admitted for an elective laparoscopic cholecystectomy. 5. A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. This preoperative procedure is done to a. Decrease expected blood loss during surgery b. Eliminate any risk of infection c. Ensure that the bowel is sterile d. Reduce the number of intestinal bacteria 6. As the nurse obtains informed consent, the client asks “now what exactly are they going to do to me?” What is the nurse’s response? a. Contract the anesthesiologist b. Contact the surgeon c. Explain the procedure d. Have the client sign the form 7. At 8:00 am, the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? a. An allergy to iodine and shellfish b. Being nauseated after a previous surgery c. Having a small glass of juice at 7:00 am d. Expressing anxiety about the surgery 8. The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? a. Age 59 years b. General anesthesia complications experienced by the client’s brother c. Diet-controlled diabetes mellitus d. Ten pounds (4.5 kg) over the client’s ideal body weight 9. An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? a. Ensure written consultation of two noninvolved physicians b. Read the surgeon’s consult to determine whether the client’s condition is lifethreatening. c. Sign the operative permit d. Withhold surgery until the next of kin is notified. 10. The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? a. “I will take off my stocking one to three times a day for 30 minutes” b. “my stockings are to loose” c. “It’s better if they are too tight rather than too loose” d. “these stockings help promote blood flow” 11. Colostomy surgery is categorized as what type of surgery? a. Cosmetic b. Curative c. Diagnostic d. Palliative 12. Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? a. Creatinine, 1.9 mg/dL (168 mcmol/L) b. Fasting glucose, 80 mg/dL (4.4 mmol/L) c. Potassium, 3.9 mEq/L (3.9 mmol/L) d. Sodium, 140 mEq/L (140 mmol/L) 13. During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? a. “I am taking vitamins” b. “I drink a glass of wine a night” c. “I had a heart attack 4 months ago” d. “I quit smoking 10 years ago” 14. A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? a. Use electric clippers to cut hair at the surgical site b. Start an infusion of lactated ringer’s solution at 75 ml/hr c. Administer one-half of the client’s usual lispro insulin dose d. Draw blood for glucose, electrolyte, and complete blood count values. 15. An older client’s adult child tells the nurse that the client does not want life support. What does the nurse do first? a. Call the legal department to draft the paperwork b. Document this in the chart c. Thank the person and do nothing else d. Talk to the client Chapter 15 1. During surgery, who is most responsible for monitoring for possible breaks in sterile technique? a. Circulating nurse b. Holding nurse c. Anesthesiologist d. Surgeon 2. A surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation occurs during surgery. What is the nurse’s proper action? a. Call the legal department b. Call the client’s primary health care provider c. Honor the DNR order d. Resuscitate per OR procedure 3. The nurse anesthetist notices that a surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse anesthetist’s initial action? a. Administer cardiopulmonary resuscitation b. Continue as normal c. Immediately stop all inhalation anesthetic agents and succinylcholine d. Inform the surgeon 4. The charge nurse for a hospital operating room is making client assignments for the day. Which client is mot appropriate to assign to the least-experienced circulating nurse? a. The 20-year-old client who has a ruptured appendix and is having an emergency appendectomy b. The 28-year-old client with a fracture femur who is having an open reduction and internal fixation c. The 45-year-old client with coronary artery disease who is having coronary artery bypass grafting d. The 52-year-old client with stage 1 breast cancer who is having tunneled central venous catheter placed 5. As the unit nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do after verifying the procedure with the client? a. Calls the surgeon b. Calls the anesthesiologist c. Gives the medication as ordered d. Asks the client to sign the consent form 6. A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? a. “are you Mr. smith?” b. “Good morning, Mr. smith” c. “what is your name, and when were you born? d. “What surgery are you having today?” 7. Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning? a. Apply elastic stocking to lower extremities b. Monitor for excessive blood loss c. Pad bony prominences d. Secure joints on a board in anatomic positions 8. Who is most likely person to administer blood products in an operating suite? a. Circulating nurse b. Holding nurse c. Scrub nurse d. Specialty nurse 9. A preoperative client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client’s anxiety? a. Actively listen to this client’s concerns b. Allow the client to wear the hearing aid to surgery c. Ask if the client may wear the hearing aid until anesthesia is given d. Explain that it is hospital policy to remove a hearing aid before surgery 10. A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? a. Decreased sensation in the lower extremities b. Diminished peripheral pulses in the lower extremities c. Pale, cool extremities d. Reddened areas over bony prominences 11. Which staff member will be best for the nurse manager to assign to update standard nursing care plans and polices for care of the client in the operating room (OR)? a. Surgical technologist with 10 years of experience in the OR at this hospital b. Certified registered nurse first assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals c. Holding room RN who has worked in the hospital holding room for longer than 15 years d. Circulating RN who has been employed in the hospital OR for 7 years 12. A client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client’s privacy will be maintained? a. Remind the client that she will be asleep b. Ensure that drapes will minimize perianal exposure c. Explain postoperative expectations d. Restrict the number of technicians in the procedure 13. If sterile gauze falls to the ground and hits the front of the ssurgeon’s gown on the way down, what does the nurse do to ensure proper infection control? a. Helps the surgeon change the gown b. Picks the gauze up with a pair of sterile gloves c. Pick the gauze up without touching the surgeon d. Sprays an antimicrobial on the surgeon’s gown 14. Which statement by a nursing student indicates a need for further teaching about operating room (OR) surgical attire? a. “I must cover my facial hair” b. “I don’t need a sterile gown to be in the OR” c. “If I go into the OR, I must wear a protective mask” d. “My scrubs will be sterile” Chapter 16 1. The nurse is performing a dressing change on a client who underwent abdominal surgery 6 days prior. The nurse notes a moderate amount of serosanguineous drainage on the old dressing. What will the nurse do? a. Apply extra gauze to the new dressing b. Contact the surgeon to discuss the need for antibiotics c. Notify the surgeon about possible wound dehiscence d. Perform the dressing change according to unit protocol 2. In conducting a postoperative assessment of a client, what is important for the nurse to examine first? a. Breathing pattern b. Level of consciousness c. Oxygen saturation d. Surgical site 3. Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? a. Heart rate of 58 beats/min b. Pale, cool extremities c. Respiratory rate of 6 breaths/min d. Suppressed gag reflex 4. Which client is at greatest risk for slow wound healing? a. A 12-year-old healthy girl b. A 47-year-old obese man with diabetes c. A 48-year-old woman who smokes d. A 98-year-old healthy man 5. Five RNs from other units have been assigned to the post-anesthesia care unit for the day. A 16-year-old client with diabetes has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the RN with which kind of experience to care for this new client? a. RN who usually works on the inpatient pediatric unit b. RN who provides education to diabetic clients in a client c. RN who has 5 years of experience in the delivery room d. RN who ordinarily work as a scrub nurse in the OR 6. The nurse assesses a client’s wound 24 hours postoperatively. Which finding causes the nurse the greatest concern and should be reported to the surgeon? a. Crusting along the incision line b. Redness and swelling around the incision c. Sanguineous drainage at the suture site d. Serosanguineous drainage on the dressing 7. The nurse reviews a routine discharge teaching plan concerning postoperative care with a client. Which statement by the client indicates that teaching about wound care was effective? a. “I may need to restrict my activities for several months” b. “I should remove the dressing if the wound is draining” c. “some bleeding from the incision is normal for several weeks” d. “The wound will completely heal in about 2 months” 8. A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement true about his client? a. Supplemental pain reduction is needed b. One dose is needed c. This an acute emergency d. The client will be hostile 9. How does the nurse position a client with postoperative nausea and vomiting? a. Flat in bed, with the head in alignment with the body b. Prone, with the head of the bed flat c. Side-lying, with the head in a neutral position d. Supine in bed, with the neck flexed 10. After gastric surgery, a client arrives in the post-anesthesia care unit. Which nursing action is most appropriate for the RN to delegate to the experience nursing assistant? a. Monitor respiratory rate and airway patency b. Irrigate the nasogastric tube with saline c. Position the client on the left side d. Assess the client’s pain level 11. Which action does the nurse implement for a client with wound evisceration? a. Apply direct pressure to the wound b. Cover the wound with a sterile, warm, moist dressing c. Irrigate the wound with warm, sterile saline d. Replace tissue protruding into the opening 12. The RN has just received report about all of these clients on the inpatient surgical unit. Which client does the nurse care for first? a. A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing b. A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home c. A 48-year-old who had a bladder surgery earlier in the day and is reporting pain when coughing d. A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4 F (38 C) 13. A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the post-anesthesia care unit? a. Pain at the surgical site b. Requirement for verbal stimuli to awaken c. Snoring sounds when inhaling d. Sore throat on swallowing 14. What pain management does a client who has been admitted to the post-anesthesia care unit typically receive? a. Intramuscular nonopioid analgesics b. Intramuscular opioid analgesics c. Intravenous nonopioid analgesics d. Intravenous opioid analgesics 15. An RN and an LPN/LVN are working together in caring for a client who need all of these intervention after orthopedic surgery. Which action (s) would be best for the RN to accomplish? a. Reinforce the need to cough and deep-breathe every 2 to 4 hours b. Develop the discharge teaching plan in conjunction with the client c. Administer narcotic pain medication before assisting the client with ambulation d. Listen for bowel sounds and monitor the abdomen for distention and pain Chapter 17 evolve 1. Which home health nurse should the nurse manager assign to care for an 18-year-old client with kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)? a. RN who has worked for the home health agency for 5 years in maternal-child health b. RN who has extensive critical care nursing experience and has worked in home health for a year c. RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit d. RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency 2. A client who is exposed to invading organisms recovers rapidly after the invasion without damage to health body cells. How has the immune response protected the client? a. Intact skin and mucous membrane b. Self-tolerance c. Inflammatory response against invading foreign proteins d. Antibody-antigen interaction 3. Which nursing activity can the nurse delegate to a home health aide? a. Changing the dressing for a client with a low absolute neutrophil count b. Assisting with bathing for a client with chronic rejection of a liver transplant c. Teaching a client with bacterial pneumonia how to take the prescribed antibiotic d. Assessing incisional tenderness for a client who had a recent kidney transplant 4. The nurse is teaching a client about cyclosporine (Sandimmune) therapy after liver transplantation. Which client statement indicates the need for further teaching? a. “I will be on this medicine for the rest of my life” b. “I must undergo regular kidney function tests” c. I must regularly monitor my blood sugar” d. My gums may become swollen because of this drug” 5. Because of the flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner? a. Older adult client with history of congestive heart failure, oxygen saturation of 91%, and on O2 at 2 L, with white blood cell count (WBC) 150,000 mm3 (15.5 x 109/L), segmented neutrophils (segs)(8.0 x 109/L), bands 5% (0.5 x 109/L), lungs with slight crackles in bases, able to assist with activities of daily living, and afebrile b. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear WBC count 9,500 mm3 (9.5 x 109/L), segs (6.o x 109/L), bands 1.0% (0.1 x 109/L), oxygen saturation of 93% on room air, and afebrile c. Young adult client with crackles in all lung lobes, with productive cough of copious amounts of thick yellow sputum, WBC count 20,000 mm3 (20.0 x 109/L), segs (7.0 x 109/L), bands 10.0% (1.1 x 109/L), oxygen saturation of 95% on O2 at 2 L, and temperature of 100.4 F (38C) d. Older adult client with recent history of rip hip replacement, with productive cough, WBC count 3,400 mm3 (3.4 x 109/L), segs (6.2 x 109/L), bands 5% (0.5 x 109/L), lungs with crackles right mid-lobe posterior chest wall, oxygen saturation of 89% with O2 at 2 L, and afebrile 6. Which statement accurately explain otitis media? a. The inflammatory response is triggered by the invasion of foreign proteins b. Phagocytosis by macrophages and neutrophils destroy and eliminates foreign invaders c. In is caused by a left shift or increase in immature neutrophils d. Many immune system cells release into the blood have specific effects 7. The nurse is preparing a client for discharge on postoperative day 1 after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client’s discharge plan? a. Please report any increased redness, swelling, warmth, or pain to your health care provider b. Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed c. A referral has been made to the American Cancer society’s reach to recovery program, and a volunteer will call you next week d. Avoid the prone and hunchback positions, and ask your health care provider for any other needed activity restrictions 8. Which statement best exemplifies a client’s protection from cancer provided by cell-mediated immunity (CMI) after exposure to asbestos? a. Cytotoxic and cytolytic T cells destroy cells that contain the major histocompatibility complex of a processed antigen b. Helper and inducer T cells recognize self-cells versus non-self-cells and secrete lymphokines that can enhance the activity of white blood cells c. Suppressors T cells prevent hypersensitivity when a client is exposed to non-self-cells or to proteins d. Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1 9. Which postoperative kidney transplantation client does the nurse asses first for signs and symptoms of hyperacute rejection? a. Older adult with Parkinson disease receiving a donation from an identical twin b. Grand multipara female with a history of subsequent blood transfusions c. Middle-aged man with a 20-pack-year history d. Young adult with type 1 diabetes 10. A complete blood count with differential is performed on a client with chronic sinusitis. Which finding does the nurse expect? a. Segmented neutrophils, 62% b. Lymphocytes, 28% c. Bands, 5% d. Basophils, 4% Chapter 18 Evolve 1. A client diagnosed with exacerbation of systemic sclerosis (SSc) asks the nurse why a foot board and a bed cradle have been placed on the bed. The nurse explains that they are used for what purpose? a. Inspect skin for lesions or changes b. Promote comfort from Raynaud’s phenomenon c. Prevent foot drop and contractures d. Decrease chilling of the extremities 2. The home health nurse conducts a community presentation of Lyme disease for the resident of an assisted living facility. Which statement from the audience indicates to the home health nurse that further instruction is needed? a. I will gently remove the tick with tissue and then burn it to prevent the spread of the disease b. It is best to walk in the center of an outside trial c. I should wait 4 to 6 weeks after being bitten by a tick to be tested for Lyme disease d. I’ll wear light-colored clothes wit