1. A nurse is reviewing the diagnostic tests prescribed for a client. The nurse notes that a lupus cell preparation (LE cell prep) has been ordered. The nurse determines that this test is used to screen primarily for which of following disorders?
a. Histoplasmosis
b. Systemic lupus erythematosus (SLE)
c. Human immunodeficiency virus (HIV)
d. Progressive systemic sclerosis
2. The nurse is caring for a hospitalized client with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine (Videx). The nurse contacts the physician if which laboratory result is noted that may be an indication of potential pancreatitis?
a. Increased potassium
b. Increased serum triglycerides
c. Increased blood urea nitrogen
d. Increased creatinine
3. A client seeks treatment for a fractured radius. There is an open wound on the arm through which jagged bone edges protrude. The nurse determines that the client has a
a. Greenstick fracture
b. Comminuted fracture
c. Open fracture
d. Simple fracture
4. The client has been admitted to the hospital with a fractured pelvis sustained in a motor vehicle accident. The nurse monitors for complications and assesses the client most closely for which of the following complications in the early post-trauma period?
a. Bradycardia
b. Pain
c. Hematuria
d. Fever
5. The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. Which finding indicates an early sign of increased intracranial pressure?
a. Increase in systolic blood pressure
b. Decreasing level of consciousness
c. Shallow, slow respirations
d. Decrease in pulse rate
6. The nurse is performing an assessment on a client with a diagnosis of Bell’s palsy. The nurse would expect to observe which of the following symptoms in the client?
a. Twitching on the affected side of the face
b. Ptosis of the eyelid and closure of the eye
c. Facial drooping
d. Periorbital edema
7. A client with a diagnosis of multiple myeloma is admitted to the hospital. On assessment, the nurse asks the client which question that specifically relates to a clinical manifestation of this disorder?
a. "Are you having any bone pain?"
b. "Do you have diarrhea?"
c. "Have you noticed an increase in appetite?"
d. "Do you have feelings of anxiety and nervousness, together with difficulty sleeping?"
8. The nurse is preparing to care for a client with a diagnosis of metastatic cancer and notes documentation in the client’s chart that the client is experiencing cachexia. Which of the following would the nurse expect to note on assessment of the client?
a. Sunken eyes and a hollow cheek appearance
b. Periorbital edema and swelling around the ears
c. Generalized edema and the presence of weight gain
d. Increased blood pressure and ascites
9. A nurse is caring for a client receiving hemodialysis who has an internal arteriovenous fistula. The nurse expects to note which finding if the fistula is patent?
a. White fibrin specks noted in the fistula
b. Palpation of a thrill over the site of the fistula
c. Lack of a bruit at the site of the fistula
d. Warmth and redness at the site of the fistula
10. A physician's office nurse is assessing a client who recently had a renal transplant. The nurse monitors for which signs of acute graft rejection?
a. Hypotension, graft tenderness, and anemia
b. Hypertension, oliguria, thirst, and hypothermia
c. Fever, vomiting, hypotension, and copious amounts of dilute urine
d. Fever, hypertension, graft tenderness, and malaise
11. A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when
a. Suctioning is required frequently
b. Excessive secretions are suctioned from a tracheostomy
c. The client’s skin and mucous membranes are light pink
d. Aspiration of gastric contents occurs during suctioning
12. A nurse is performing a cardiovascular assessment on a client with heart failure. Which of the following items would the nurse assess to gain the best information about the client’s left-sided heart function?
a. Breath sounds
b. Peripheral edema
c. Jugular vein distention
d. Hepatojugular reflux
13. A nurse suctioning a client through an endotracheal tube monitors the client for complications associated with the procedure. Which of the following indicates a complication?
a. A blood pressure of 138/88 mm Hg
b. An irregular heart rate
c. A reddish coloration in the client's face
d. A pulse oximetry level of 95%
14. An emergency department nurse is assessing a client who sustained a blunt chest injury and suspects the presence of flail chest. Which specific characteristic finding would the nurse note in this condition?
a. Slow deep respirations
b. Asymmetric chest movement
c. Loss of consciousness
d. Anxiety
15. A nurse is caring for a client with a tracheostomy tube and is monitoring the client for subcutaneous emphysema. The nurse identifies this complication by noting which of the following?
a. Crackling sounds heard in the upper lobes bilaterally
b. A puffy and crackling sensation on palpation of the tissues surrounding the tracheostomy site
c. Signs of respiratory distress
d. Dyspnea
16. A nurse is monitoring a client with a tracheostomy tube for complications related to the tube. The nurse suspects tracheoesophageal fistula if which of the following is noted?
a. Abdominal distention
b. Excess mucus production
c. Abnormal skin and mucous membrane color
d. Use of accessory muscles to assist with breathing
.
17. A nurse is assessing a client who was treated for an asthma attack. The nurse determines that the client's respiratory status has worsened if which of the following is noted?
a. Loud wheezing
b. Wheezing during inspiration and expiration
c. Wheezing on expiration only
d. Diminished breath sounds
18. A nurse is reviewing the assessment findings and laboratory results of a child diagnosed with new-onset glomerulonephritis. Which of the following findings would the nurse most likely expect to note?
a. Increased creatinine levels
b. Hypotension
c. Low serum potassium
d. Tea-colored urine
19. A nurse is reviewing the record of an infant admitted to the newborn nursery. The nurse notes that the physician has documented bladder exstrophy. On assessment of the infant, the nurse expects to note which of the following?
a. Undescended or hidden testes
b. The opening of the urethral meatus below the normal placement on the glans penis
c. The opening of the urethral meatus on the ventral side of the glans penis
d. The urinary bladder on the outside of the body
20. A newborn infant with a diagnosis of subdural hematoma is admitted to the newborn nursery. The nurse does which of the following to assess for the major symptom associated with subdural hematoma?
a. Checks for contractures of the extremities
b. Tests for equality of extremities when stimulating reflexes
c. Monitors the urinary output pattern
d. Monitors the urine for blood
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