RENR STEM ANALYSIS QUESTIONS

1. A nurse working in an outpatient clinic is assessing a client who reports night sweats and
fatigue. He states he has had a cough along with nausea and diarrhea. His temperature is 38.1° C
(100.6° F) orally. The client is afraid he has HIV.

Which of the following actions should the nurse NOT take?

A. Perform a physical assessment.
B. Determine when current symptoms began.
C. Draw blood for HIV testing.
D. Obtain a sexual history.

2. A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE).
The client reports fatigue, joint tenderness, swelling, and difficulty urinating.

Which of the following laboratory findings should the nurse NOT anticipate?
A. Positive ANA
B. Increased hemoglobin
C. 2+ urine protein
D. Elevated BUN

3. A nurse in an oncology clinic is reviewing the health record of a client who had surgery to
stage ovarian cancer. The nurse reviews the following diagnostic notation on the pathology
report: T2-N3-MX.

Which of the following is an expected finding that supports this diagnosis?

A. The tumor is 4 cm in size involving the ovary and adjacent tissues.
B. No lymph nodes contain cancer cells.
C. The tumor is receptive to current medication therapy.
D. The cancer has metastasized to other areas in the body.

4. A patient approaches the nurse and impatiently blurts out, “You’ve got to help me! Something
terrible is happening. My heart is pounding”. The nurse responds, “It’s almost time for visiting
hours. Let’s get your hair combed.”

Which approach has the nurse used?

a. Bringing up an irrelevant topic
b. Responding to physical needs
c. Addressing false cognitions
d. Focusing

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5. A patient with a high level of motor activity runs from chair to chair and cries, They’re
coming! They’re coming! The patient does not follow instructions or respond to verbal
interventions from staff.

The initial nursing intervention of highest priority is to:

a. provide for patient safety.
b. increase environmental stimuli.
c. respect the patients personal space.
d. encourage the clarification of feelings.

6. A patient with a high level of motor activity runs from chair to chair and cries, They’re
coming! They’re coming! The patient is unable to follow instructions or respond to verbal
interventions from staff.

Which nursing diagnosis has the highest priority?

a. Risk for injury
b. Self-care deficit
c. Disturbed energy field
d. Disturbed thought processes

7. A supervisor assigns a worker a new project. The worker initially agrees but feels resentful.
The next day, when asked about the project, the worker says, I’ve been working on other things.
When asked 4 hours later, the worker says, “Someone else was using the copier, so I couldn’t
finish it.”

The worker’s behaviour demonstrates:

a. acting out.
b. projection.
c. suppression.
d. passive aggression.

8. A 19-year-old male client is being treated for a drug addiction. He continually voices his dread
of being discharged because he knows he will have to live with his parents and follow their rules
until he can earn enough money to live on his own. He is showing increasing resistance to
treatment measures, such as attending group sessions, but is refusing to acknowledge that he has
an addiction or that he needs treatment.

Which behaviour is the client demonstrating?

a. Transference
b. Primary resistance
c. Secondary resistance
d. Tertiary resistance

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9. The nurse is collecting data at the clinic from a new client who is being seen for an employee
physical. The client informs the nurse that both parents have a history of high blood pressure and
his father had a stroke at age 52 years. The nurse discusses diet and exercise programs that may
benefit the client.

What is the nurse displaying with this information?

a. Illness prevention
b. Early detection
c. Health maintenance
d. Health promotion

10. Which of the following statements by a mother would indicates to the nurse that a three-year-
old is achieving the normal developmental milestones?

a. “he accepts limits”

b. “he shares his toys”
c. “he dresses himself”
d. “he helps with chores”

11. A nurse is caring for a client who has sustained burns to 35% of his total body surface area.
Of this total, 20% are full-thickness burns on the arms, face, neck, and shoulders. The client’s
voice is hoarse, and he has a brassy cough.

These findings are indicative of which of the following?

A. Pulmonary edema
B. Bacterial pneumonia
C. Inhalation injury
D. Carbon monoxide poisoning

12. A nurse is caring for a client who was admitted 24 hr. ago with deep partial-thickness and
full-thickness burns to 40% of his body.

Which of the following are expected findings in this client?

A. Hypertension
B. Bradycardia
C. Hyperkalemia
D. Decreased hematocrit

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13. A client asks a nurse why the provider bases his medication regimen on his HbA1c instead of
his log of morning fasting blood glucose results.

Which of the following is an appropriate response by the nurse?

A. “HbA1c measures how well insulin is regulating your blood glucose between meals.”
B. “HbA1c indicates how well your blood glucose has been regulated over the past 3 months.”
C. “A test of HbA1c is the first test to determine if an individual has diabetes.”
D. “A test of HbA1c determines if the dosage of insulin needs to be adjusted.”

14. A nurse is providing instructions to a client who has Graves’ disease and has a new
prescription for propranolol (Inderal).

Which of the following information should the nurse include?

A. An adverse effect of this medication is jaundice.
B. Take your pulse before each dose.
C. The purpose of this medication is to decrease production of thyroid hormone.
D. You should stop taking this medication if you have a sore throat.

15. A nurse is preparing to receive a client from the High Dependency Unit who is postoperative
following a thyroidectomy.

Which of the following equipment is NOT necessary?

A. Suction equipment
B. Humidified air
C. Flashlight
D. Tracheostomy tray

16. A nurse is reinforcing teaching with a client who has been prescribed levothyroxine
(Synthroid) to treat hypothyroidism.

Which of the following should the nurse NOT include in the teaching?
A. Weight gain is expected while taking this medication.
B. Medication should not be discontinued without the advice of the provider.
C. Follow-up serum TSH levels should be obtained.
D. Take the medication on an empty stomach.

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17. The elderly spouse of a 74-year-old male client states that she has noticed that her husband
doesn’t remember as well as he used to. She explains that he has been putting on his coat before
his shirt, and that he can never get their cheque book to balance as it did in the past.

The client is exhibiting signs and symptoms typical of:

a. Vascular dementia
b. Alzheimer’s disease
c. Acute delirium
d. Aging

18. For those family members who desire to care at home for loved ones who have been given a
diagnosis of Alzheimer’s disease, it is important for the nurse to ensure that the family is aware of
which caregiver skills and responsibilities will be necessary.

What is one of the responsibilities of the caregiver during the middle stage of the disease?
a. Helping the loved one with memory and communication problems
b. Providing a stable, routine environment
c. Providing complete assistance with physical care
d. Adapting to the changing personality and behaviour of the loved one

19. The father of three young children dies. The wife expresses how worried she is about how to
raise the children on her own without the support of her husband. She finds herself crying and
living through each day without accomplishing anything.

In which grieving stage is this behaviour typically experienced?

a. Denial
b. Depression and identification
c. Acceptance and recovery
d. Yearning

20. Three years after the loss of her husband of 35 years, the wife has a full-time job but finds
that she cannot sleep well at night, has frequent mood changes, and attends the couple’s night out
with friends that she and her husband attended.

Upon seeking counselling, she discovers that she is exhibiting symptoms of:
a. Bereavement-related depression
b. Complicated grief
c. Anticipatory grief
d. Caregiver grief

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21. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the
child exhibits jerky movements with his arms as he tries to eat.

The nurse recognizes that he has which type of cerebral palsy?

a. Athetoid
b. Ataxic
c. Spastic
d. Mixed

22. The nurse would observe a child for frequent swallowing after a tonsillectomy and
adenoidectomy (T&A).

What might this indicate?

a. Bleeding from the surgical site
b. Pain at the incision area
c. Sore throat from postnasal drip
d. Potential vomiting

23. The nurse observes a patient lying rigidly in bed and taking shallow breaths. The patient
reports a pain score of 4 out of 5 and says, My leg hurts.

The nurse determines that the objective and subjective data are
a.incongruent and require more assessment.
b.insufficient to make any conclusions.
c.congruent and support that the patient is in pain.
d.unclear; the nurse needs to talk to the patient’s family for more information.

24. The nurse forgets to give the patient a dose of antibiotic. Later in the shift, the patient goes
into cardiac arrest and dies.

What element is lacking to support malpractice?

a. Duty of care
b. Breach of duty
c. Specific injury
d. Proximate cause

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25. A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes mellitus
and reports difficulty following the diet and remembering to take the prescribed medication.

Which of the following is NOT an appropriate action by the nurse?

A. Ask the dietitian to assist with meal planning.
B. Contact the client’s support system.
C. Assess for age-related cognitive awareness.
D. Encourage the use of a daily medication dispenser.

26. A nurse is caring for a client who was just told she has breast cancer and the nurse evaluates
the client’s response.

Which of the following statements by the client reflects a lack of understanding of an illness
perspective?
A. “I have no family history of breast cancer.”
B. “I need a second opinion; there is no lump.”
C. “I am glad we live in the city near several large hospitals.”
D. “I will schedule surgery next week, over the holidays.”

27. A nurse in the emergency department is assessing a client who is unresponsive. The client’s
partner states, “He was pulling weeds in the yard and dropped to the ground.”

Which of the following techniques should the nurse use to open the client’s airway?
A. Head-tilt, chin-lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head

28. A nurse is reviewing the common emergency management protocol for clients during a
cardiac emergency.

Which of the following is an appropriate action by the nurse?

A. Administer IV dobutamine (Dobutrex).
B. Administer IV dopamine (Intropin).
C. Administer IV epinephrine (Adrenaline).
D. Administer IV atropine (Atropair).

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29. A nurse is reviewing the health record of a student newly admitted to a university and living
in a dormitory. The health record indicates the student requires follow-up immunizations.

Which of the following organisms should the nurse plan to vaccinate the student against?
A. Streptococcus pneumoniae
B. Neisseria meningitidis
C. Bartonella henselae
D. Rickettsia rickettsii

30. A nurse is caring for a client who was recently admitted to the emergency department
following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations
of 22 bpm, and a laceration on his forehead that is bleeding.

Which of the following is the priority nursing action at this time?

A. Keep neck stabilized.
B. Insert naso gastric tube.
C. Monitor pulse and blood pressure frequently.
D. Establish IV access and start fluid replacement.

31. A 30-year-old female with sudden abdominal pain is rushed to the emergency room. On
examination, her skin is cold and clammy, she is in obvious painful distress and she says that she
expected her period two weeks ago. What would be your IMMEDIATE nursing management for
this client?

A. Prepare the client for surgery

B. Inform the charge nurse on duty
C. Check her vital signs, including a blood glucose check
D. Inform the doctor on duty immediately of the client’s condition

32. A nurse is caring for a client who has dyspnea and is to receive oxygen continuously.

Which of the following oxygen devices should the nurse use to deliver a precise amount of
oxygen to the client?
A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask

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33. A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The
partner states the client woke up this morning, did not recognize him, and did not know where she
was. The client reports chills and chest pain that is worse upon inspiration.

Which of the following is the priority nursing action?

A. Obtain baseline vital signs and oxygen saturation.
B. Obtain a sputum culture.
C. Obtain a complete history from the client.
D. Provide a pneumococcal vaccination.

34. A nurse is caring for a client who has pneumonia. Assessment findings include temperature
37.8° C (100° F), respirations 30/min, BP 130/76, heart rate 100/min, and SaO2 91% on room air.

Using a scale of 1 to 4, with 1 being the highest priority, which nursing intervention should be
given the HIGHEST priority?
A. Administer antibiotics as prescribed.
B. Administer oxygen therapy.
C. Perform a sputum culture.
D. Administer an antipyretic medication to promote client comfort.

35. A nurse in a clinic is caring for a client who has sinusitis.

Which of the following techniques should the nurse use to identify clinical manifestations of this
disorder?
A. Percussion of posterior lobes of lungs
B. Auscultation of the trachea
C. Inspection of the conjunctiva
D. Palpation of the orbital areas

36. A nurse working at a battered woman’s shelter is counselling a pregnant woman who has just
entered the shelter.

When assessing the client’s history, which information would the client most likely report?
a. A history of abuse before pregnancy
b. A history of child abuse
c. A history of multiple pregnancies
d. A history of substance abuse

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37. Which role would be most appropriate for an undergraduate-level prepared nurse working
with a mental health population?

a. Prescribe medications and have hospital admission privileges.

b. Work as a case manager for large groups of persons with mental illness.
c. Assess clients in acute psychiatric hospital settings.
d. Provide basic primary, secondary, and tertiary services.

38. A nurse is counseling a client following an unexpected loss.

If given adequate support and adaptation, the client will most likely:
a. Recover from the crisis and become mentally ill
b. Avoid the loss and potential mental illness
c. Be able to ignore the grief
d. Resume previous lifestyle in spite of sadness

39. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The
client states that she is anxious because she feels that she cannot get enough air. Vital signs are:
heart rate 117/min, respiratory rate 38/min, temperature 38.4° C (101.2° F), and blood pressure
100/54 mm Hg.

Which of the following actions is the priority action at this time?

A. Notify the provider.
B. Administer heparin via IV infusion.
C. Administer oxygen therapy.
D. Obtain a spiral CT scan.

40. A nurse is assessing a client who has experienced a gunshot wound. Findings include blood
pressure 108/55 mm Hg, heart rate 124/min, respiratory rate 36/min, temperature 38.6° C (101.4°
F), and SaO2 95% on oxygen 15 L/min via nonrebreather mask. The client reports dyspnea and
pain. The nurse reassesses the client 30 min later.

Which of the following should the nurse NOT report to the doctor?
A. Distended neck veins
B. Tracheal deviation
C. Headache
D. Heart rate 154/min

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41. A nurse in the emergency department is assessing a client who was in a motor vehicle crash.
Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68
mm Hg, heart rate 124/min, respiratory rate 38/min, temperature 38.6° C (101.4° F), and SaO2
92% on room air.

Which of the following actions should the nurse take first?

A. Obtain a chest x-ray.
B. Prepare for chest tube insertion.
C. Administer oxygen via a high-flow mask.
D. Initiate IV access.

42. The nurse is caring for a patient who is receiving isotonic intravenous (IV) fluids at an
infusion rate of 125 mL/hour. The nurse performs an assessment and notes a heart rate of 102
beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs.

Which action will the nurse take?

A. Decrease the IV fluid rate and notify the provider.
B. Increase the IV fluid rate and notify the provider.
C. Request an order for a colloidal IV solution.
D. Request an order for a hypertonic IV solution.

43. A client has less than the normal amount of bicarbonate in the blood and other extracellular
fluids.

What response does the nurse anticipate?

A. Increased risk for acidosis
B. Decreased risk for acidosis
C. Increased risk for alkalosis
D. Decreased risk for alkalosis

44. The nurse monitors for which acid-base imbalance in a client who has hypoxemia?

A. Reduced carbon dioxide production leading to alkalosis

B. Reduced carbon dioxide retention leading to alkalosis
C. Excess carbon dioxide production leading to acidosis
D. Excess carbon dioxide retention leading to acidosis

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45. The nurse monitors for which acid-base problem in a client who is taking furosemide (Lasix)
for hypertension?

a. Acid excess secondary to respiratory acidosis

b. Acid deficit secondary to respiratory alkalosis
c. Acid excess secondary to metabolic acidosis
d. Acid deficit secondary to metabolic alkalosis

46. A nurse is caring for a client who has heart failure and reports increased shortness of breath.
The nurse increases the oxygen per protocol.

Which of the following actions should the nurse take first?

A. Obtain the client’s weight.
B. Assist the client into High-Fowler’s position.
C. Auscultate lungs sounds.
D. Check oxygen saturation with pulse oximeter.

47. A nurse is completing the admission physical assessment of client who has a history of mitral
valve insufficiency.

Which of the following is an expected finding?

A. Hoarseness
B. Petechiae
C. Crackles in lung bases
D. Splenomegaly

48. A nurse is caring for a client who has chronic venous insufficiency. The doctor prescribed
thigh-high compression stockings.

The nurse should instruct the client to

A. Massage both legs firmly with lotion prior to applying the stockings.
B. Apply the stockings in the morning upon awakening and before getting out of bed.
C. Roll the stockings down to the knees if they will not stay up on the thighs.
D. Remove the stockings while out of bed for 1 hr, four times a day to allow the legs to rest.

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49. A nurse is caring for a client who is admitted to the emergency department with a blood
pressure of 266/147 mm Hg. The client reports a headache and states that she is seeing double.
The client states that she ran out of her diltiazem (Cardizem) 3 days ago and she has not been able
to purchase more.

Which of the following nursing interventions should the nurse expect to perform FIRST?
A. Administer acetaminophen for headache.
B. Provide teaching in regard to the importance of not abruptly stopping an antihypertensive.
C. Obtain IV access and prepare to administer an IV antihypertensive.
D. Call social services for a referral for financial assistance in obtaining prescribed medication.

50. A nurse in the emergency department is caring for a client who has an allergic reaction to a
bee sting. The client is experiencing wheezing and swelling of the tongue.

Which of the following medications should the nurse expect to administer first?
A. Methylprednisolone (Solu-Medrol) IV bolus
B. Diphenhydramine (Benadryl) subcutaneously
C. Epinephrine (Adrenaline) IV
D. Albuterol (Proventil) inhaler

51. The process of dynamic change with adaptation in the systems parts, and how community
systems and subsystems interact is known as:

a. Structure of a community.
b. Community health promotion.
c. Community diagnosis.
d. Function of a community.

52. A nurse is assessing a community from both a developmental and risk perspective.

Which of the following characteristics would be of most interest to the nurse?

a. Gender
b. Age
c. Race
d. Socioeconomic level

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53. After assessing the community, the nurse concludes that the community is having difficulty
meeting its nutritional-metabolic pattern.

Which of the following findings would the nurse most likely have discovered during the
assessment?
a. Decreased availability of grocery stores
b. Poor nutritional habits
c. Lack of subsidized food programs
d. Inadequate knowledge about proper nutrition

54. A nurse has recently accepted the position of unit nurse manager on a long-term care unit.

Which of the following directives should the nurse give to the staff nurses?
a. Encourage residents to participate in unit activities such as Scrabble and bingo.
b. Demonstrate the caring aspect of nursing by dressing residents before breakfast.
c. Fill in missing words during conversation with the residents to avoid embarrassment.
d. Instruct the aides to get residents ready for breakfast as quickly as possible to make sure they
are ready to eat.

55. A nurse is planning a community health education program for young adults.

Which of the following considerations should be made by the nurse?

a. The age span encompassing young adulthood is between 20 to 30 years of age.
b. The number one cause of death for young adults is injury.
c. The number of young adults in the Caribbean is increasing.
d. The maternal mortality rate is at its lowest point since 1980.

56. Based on Erikson’s intimacy versus isolation and loneliness stage of development,

Which of the following adults has transitioned to this stage?

a. A 21-year-old man who has a part-time job, spends most of his leisure time with his
buddies, and has numerous short-term intimate relationships
b. A 25-year-old woman who is very concerned with how she is perceived by her coworkers
and friends
c. A 30-year-old man who just graduated with a PhD and is looking for his first full-time job
d. A 26-year-old woman who has a long-term relationship with a female companion

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57. A nurse is developing a community program to prevent violence.

Which of the following is the first action the nurse should take?
a. Talk to people who are victims of violence for their opinion.
b. Identify factors that lead to violence.
c. Develop a plan of action to combat violence.
d. Evaluate current community programs.

58. Which action would be most appropriate for the nurse to take when working with a rape
survivor?

a. Provide continuous care once the victim enters the health care system.
b. Examine evidence for its authenticity.
c. Work with the criminal justice system to find the rapist.
d. Provide long-term therapy for psychological trauma.

59. The nurse notes the laboratory testing performed on a 78-year-old client reveal a serum
glucose level of 130 mg/dL. The nurse performs an assessment on the client and notes the
absence of polyuria, polydipsia, or polyphagia.

Which of the following impressions by the nurse is most correct?

a. The client might have eaten a meal with high sugar content prior to the testing.
b. The laboratory results might be erroneous.
c. The client has type 1 diabetes mellitus.
d. The client will need to be assessed for other manifestations

60. The nurse is assessing a client newly admitted to the medical–surgical unit with
glomerulonephritis.

Which of the following classic manifestations of this disorder does the nurse expect to find?

a. Acute flank pain, nausea, and vomiting

b. Haematuria, proteinuria, and oedema
c. Headache, fever, dehydration
d. Weight loss, anaemia, and fatigue

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61 The nurse is beginning a teaching session with the patient.

Which of the following interventions should the Nurse implement before commencing the
session?
i. Seat the patient comfortably
ii. State specific objectives for the talk
iii. Set a specific time limit for the talk
iv. Encourage the patient to verbalize her needs
a. i, ii, iii
b. i, ii, iv
c. i, iii, iv
d. ii, iii, iv

62. The nurse is orienting a new graduate. The nurse is reinforcing the importance of standard
precautions.

Which of the following observations by the nurse would require further education regarding
standard precautions?
a. The graduate nurse understands to wash hands when entering and exiting the client’s room.
b. The graduate nurse wears glove when serving breakfast trays to various clients.
c. The graduate nurse wears a gown, gloves, and goggles when suctioning a client.
d. The graduate nurse leaves all supplies in the room of a client who is in contact isolation.

63. Which of the following manifestations indicates a systemic reaction associated with an
inflammatory response?

a. Erythema
b. Pain
c. Tachypnea (RR 26)
d. Edema

64. A nurse is administering a medication at the bedside.

Which of the following actions should be the first priority?

a. Document the administration of the medication.
b. Establish the identity of the client.
c. Recheck the medication label.
d. Obtain orange juice for the client to take with the medication.

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65. A client is admitted to the surgical unit after being involved in a motor vehicle accident.
During the nurse’s initial assessment, the client develops hypotension, and severe jugular
distension with a tracheal deviation.

What does the nurse suspect has occurred?

a. Hemorrhage
b. Tension pneumothorax
c. Compensatory shock
d. Hypovolemic shock

66. The nurse is performing an assessment on a client experiencing hypoparathyroidism. While

taking a blood pressure on this client, the nurse notes spasms of the hands.

The nurse should document this clinical manifestation as:

a. Chvostek’s sign.
b. Trousseau’s sign.
c. Turner’s sign.
d. Cullen’s sign.

67. When performing an endocrine assessment on a client, the nurse asks the client if she has
experienced weight changes.

Which endocrine gland would NOT provide the nurse with data about evaluating weight
changes?
a. Adrenal gland
b. Thyroid gland
c. Parathyroid gland
d. Pituitary gland

68. Which of the following best describes the nurse’s role in health promotion and disease
prevention?

a. Educating about home safety measures

b. Identifying areas for family improvement
c. Implementing the nursing process using a systems perspective
d. Acting as a role model for the family

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69. The nurse is caring for a person who is obese, sedentary, and has recently been diagnosed
with Type 2 diabetes mellitus.

Which of the following goals for the person is correctly stated?

a. The person will exercise more often.
b. The person will consume 900 calories a day.
c. The person will walk one-quarter mile a day, 5 days a week.
d. The person will eliminate all refined sugar and processed foods from her diet.

70. A colleague asks you to give her your password access so that she can view her partner’s
healthcare record.

This request violates the patients right to:

a. Privacy.
b. Confidentiality.
c. Undue authorization of treatment.
d. Protection against slander.

71. The clinic nurse understands the new description of nursing art/aesthetics as the way that
nurses and patients help each other through a circular process.

What is the event that begins this process?

A. A health threat
B. Experiencing new possibilities for health
C. Hope and understanding for the future
D. Relationship building

72. A woman gives birth to a healthy baby boy at 35 weeks’ gestation. The nurse is performing
an assessment of the neonate’s respiratory system.

What factor regarding the development of the normal respiratory system should the nurse
consider?
A. As the fetus approaches term, secretion of intrapulmonary fluid increases.
B. Lung expansion after birth suppresses the further release of surfactant.
C. Surfactant increases alveolar surface tension, allowing re-expansion after exhalation.
D. Surfactant production is sufficient to maintain alveolar stability by about 34 weeks.

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73. The antenatal nurse is assessing a woman at 36 weeks’ gestation. Her fundal height
measurement was last recorded at 34 cm. The patient’s abdomen appears to be widest from
side to side.

The nurse suspects the possibility of which type of fetal presentation?

A. Breech
B. Cephalic
C. Face
D. Shoulder

74. A nurse identifies clinical practice problems on a cardiac unit.

Which question is a background question?

a. How should a client experiencing chest pain be prioritized?
b. What is the experience of a cardiac catheterization like for middle-aged men?
c. How are a client’s vital signs affected by anxiety?
d. What is the best treatment for a myocardial infarction?

75. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base
imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33
mm Hg, and HCO3 18 mEq/L.

Which manifestation should the nurse identify as an example of the clients compensation
mechanism?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys

76. A nursing student is learning about antibody-mediated immunity.

The cell with the most direct role in this process begins development in which tissue or
organ?
a. Bone marrow
b. Spleen
c. Thymus
d. Tonsils

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77. An older adult has a mild temperature, night sweats, and productive cough. The client’s
tuberculin test comes back negative.

What action by the nurse is best?

a. Recommend a pneumonia vaccination.
b. Teach the client about viral infections.
c. Tell the client to rest and drink plenty of fluids.
d. Treat the client as if he or she has tuberculosis (TB).

78. A nurse cares for a client with right-sided heart failure. The client asks, why do I need to
weigh myself every day?

How should the nurse respond?

a. Weight is the best indication that you are gaining or losing fluid.
b. Daily weights will help us make sure that you’re eating properly.
c. The policy requires that all inpatients be weighed daily.
d. You need to lose weight to decrease the incidence of heart failure.

79. The patient is immobile and has been repositioned in bed using a drawsheet. When
finished, the patient is in a supported Fowlers position with the head of the bed elevated 45
degrees.

Which other action is important for positioning this patient?

a. Support His Calves with Pillows.
b. Place A Large Pillow Behind His Head to Prevent Extension.
c. Place A Pillow Behind His Upper Back.
d. Avoid using pillows if the patient does not have use of the hands and arms.

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