Question 1

A 4-year old male is admitted to the unit with nephritic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should?

Accepted Answer

Answer reason: Elevating the scrotum on a small pillow reduces dependent edema, improves lymphatic drainage, and decreases discomfort. In nephrotic syndrome, severe edema is common, and supportive positioning is the safest and most effective non-pharmacologic intervention for painful scrotal swelling.

Question 2

When managing a client's pain, which of the following statements BEST describes the ethical considerations of the nurse?

Accepted Answer

Answer reason: Pain is a subjective experience, and the client’s self-report is always the most reliable and ethical basis for assessment. Accepting the client’s own description prevents under-treatment and ensures that nursing care remains patient-centered, unbiased, and respectful of individual experience.

Question 3

The nurse is caring for a client in the coronary care unit two days after a myocardial infarction. The client has many questions about his condition. On which topic should the nurse focus teaching first?

Accepted Answer

Answer reason: During the acute recovery phase after a myocardial infarction, client anxiety and fear are high. The nurse should first address the client's immediate concerns and help them understand their current condition to reduce anxiety and promote psychological comfort before teaching long-term self-care.

Question 4

What is the purpose of pursed-lip breathing for a client with emphysema?

Accepted Answer

Answer reason: Pursed-lip breathing creates back pressure during expiration, helping to keep small airways open, reducing air trapping, and preventing early airway collapse. It does not strengthen inspiratory muscles, directly reduce accessory muscle use, or prolong inspiration—it prolongs expiration.

Question 5

Which of the following is not a local physiological effect of hot application?

Accepted Answer

Answer reason: Heat causes vasodilation, increases local metabolism and oxygen consumption, increases blood flow, and decreases blood viscosity. Therefore, "reduces blood flow" is not an effect of heat application.

Question 6

What is the most comfortable position for a client with acute pancreatitis?

Accepted Answer

Answer reason: Flexing the trunk and hips in the fetal position decreases the stretch on the inflamed pancreas and peritoneum, reducing pain in acute pancreatitis.

Question 7

In which position should the nurse place a client with a herniated intervertebral disk who is experiencing low back pain to minimize the pain?

Accepted Answer

Answer reason: Flexing the hips and knees with the head of the bed slightly elevated reduces lumbar lordosis and intradiscal pressure, decreasing nerve root compression and pain from a herniated disk.

Question 8

What is the appropriate treatment for swelling from a head injury?

Accepted Answer

Answer reason: Cold compresses reduce pain and swelling by causing vasoconstriction after an acute injury. Heat increases blood flow and swelling; medication is nonspecific; doing nothing is inappropriate.

Question 9

The nurse instructs a client to use pursed-lip breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?

Accepted Answer

Answer reason: Pursed-lip breathing prolongs exhalation and creates back pressure that prevents airway collapse and air trapping, improves alveolar ventilation, and aids CO2 elimination. It is not for muscle strengthening or primarily to increase oxygen intake.

Question 10

The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?

Accepted Answer

Answer reason: Pruritus with hepatitis is worsened by dry skin. Emollients help moisturize and reduce itching. Hot water and frequent showers dry the skin, and powder can irritate, so the best option is to add oil/emollient to the bath water.

Question 11

When teaching a client with chronic obstructive pulmonary disease how to conserve energy, the nurse should teach the client to lift objects?

Accepted Answer

Answer reason: During exertion COPD clients should exhale through pursed lips to prevent airway collapse, reduce air trapping, and decrease dyspnea. Inhaling or breath-holding increases work of breathing and intrathoracic pressure.

Question 12

A nurse applies an ice pack to a client's leg for 20 minutes. Which clinical indicator helps the nurse determine the effectiveness of the treatment?

Accepted Answer

Answer reason: Cold application produces local anesthesia and vasoconstriction, reducing pain sensation. It does not cause peripheral vasodilation, systemic depression of vital signs, or decreased blood viscosity (cold increases viscosity).

Question 13

Which of the pain scales will you use in a fully conscious adult patient?

Accepted Answer

Answer reason: For a fully conscious adult, the Numeric Rating Scale (0–10) is the standard and most precise tool. Wong-Baker faces is mainly for children or those with communication barriers, and simple verbal descriptors are less specific.

Question 14

The visual analogue scale is most widely used to measure?

Accepted Answer

Answer reason: A visual analogue scale (VAS) is a 10-cm line anchored by “no pain” and “worst pain,” used primarily to quantify pain intensity.

Question 15

A child with tetralogy of fallot uses which of the following positions?

Accepted Answer

Answer reason: Children with Tetralogy of Fallot instinctively assume a squatting/knee-chest position during cyanotic spells to increase systemic vascular resistance, decreasing right-to-left shunting and improving oxygenation.

Question 16

A client with Meniere’s disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?

Accepted Answer

Answer reason: Sudden head movements can provoke vertigo in Meniere’s disease; clients should move slowly. High sodium and excess fluids can worsen endolymphatic fluid, and watching TV may increase symptoms rather than relieve them.

Question 17

The nurse has given instructions on pursed-lip breathing to a client with COPD. Which statement by the client would indicate effective teaching?

Accepted Answer

Answer reason: Pursed-lip breathing involves slow inhalation through the nose and prolonged exhalation through pursed lips while contracting abdominal muscles to aid expiration. Exhalation should be longer than inhalation.

Question 18

A client who has just undergone a laparoscopic cholecystectomy complains of "free air pain." What would be your best action?

Accepted Answer

Answer reason: Post-laparoscopic "free air" pain is due to residual CO2 irritating the diaphragm, causing referred shoulder pain. Early ambulation helps disperse and absorb the gas, relieving discomfort. Deep breathing/coughing targets atelectasis, bed rest worsens, and NG suction is unnecessary.

Question 19

Which instruction should the nurse include when teaching a patient about lifestyle modifications to manage GERD?

Accepted Answer

Answer reason: Elevating the head of the bed reduces reflux by minimizing gastric contents moving into the esophagus during rest. The other options worsen GERD: large meals increase reflux, peppermint lowers LES tone, and complete avoidance of activity is unnecessary.

Question 20

Ali is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client?

Accepted Answer

Answer reason: Pruritus with jaundice requires comfort and skin-protective measures. Keeping nails short reduces skin injury from scratching. Vitamin K and IM pressure address bleeding risk, and protein restriction is not indicated for pruritus.

Question 21

What is the priority nursing goal for a client admitted with renal calculi, moderate to severe flank pain, nausea, and a temperature of 100.8°F?

Accepted Answer

Answer reason: Renal calculi cause severe renal colic; the immediate priority is to relieve acute pain. Hydration and infection prevention are important but are addressed after stabilizing pain and comfort.

Question 22

What is the most appropriate position for a client with severe burns over the face and chest who is having difficulty breathing?

Accepted Answer

Answer reason: High Fowler’s maximizes lung expansion and helps reduce airway edema and aspiration risk in facial/chest burns with respiratory distress.

Question 23

Why should the nurse question a client with AIDS about using acupuncture for pain management?

Accepted Answer

Answer reason: Acupuncture involves inserting needles; for a client with AIDS who may be immunocompromised and thrombocytopenic, needles increase infection and bleeding risk, so the nurse should question this therapy.

Question 24

Which of the following is NOT effective in enhancing strategy for a patient with impaired vision?

Accepted Answer

Answer reason: Fluorescent lighting can cause glare and flicker, which can worsen visual discomfort and hinder patients with impaired vision. Bright contrast, positioning within the patient’s visual field, and adequate lighting are helpful strategies.

Question 25

What effects should the nurse teach a preoperative client to expect regarding relaxation therapy?

Accepted Answer

Answer reason: Relaxation therapy elicits a parasympathetic 'relaxation response' mediated through increased calming neural signaling to central brain centers. This central effect underlies secondary outcomes such as lower blood pressure, slower respirations, and reduced muscle tension; the most specific physiologic descriptor listed is increased neural impulses to the brain.

Question 26

Which type of bandage is commonly used for wrapping a limb or securing dressings?

Accepted Answer

Answer reason: Roller bandages are long strips designed to wrap limbs with overlapping turns and to secure dressings; triangular bandages are mainly for slings, tubular for cylindrical support, and adhesive for small wounds.

Question 27

Which position is best to aid breathing for a patient with acute pulmonary edema?

Accepted Answer

Answer reason: High Fowler's maximizes lung expansion and reduces venous return, decreasing pulmonary congestion and easing breathing in acute pulmonary edema. Lying flat worsens symptoms; side-lying and semi-Fowler's provide less respiratory benefit.

Question 28

To facilitate maximum air exchange, in which position should the client be placed?

Accepted Answer

Answer reason: Orthopneic (sitting and leaning forward) maximizes lung expansion and use of accessory muscles, improving ventilation more than other positions.

Question 29

What position provides the most comfort for a client with suspected peritonitis reporting severe abdominal pain and guarding?

Accepted Answer

Answer reason: Flexing the knees reduces tension on the abdominal muscles and peritoneum, relieving pain; semi-Fowler’s also promotes localization of peritoneal fluid away from the diaphragm. Other positions increase discomfort or risk.

Question 30

A client is admitted with suspected appendicitis. What position is most comfortable for a client experiencing pain from appendicitis?

Accepted Answer

Answer reason: Flexing the hips and knees (side-lying with knees bent) relaxes abdominal muscles and reduces peritoneal stretch, providing the greatest comfort with appendicitis pain.

Question 31

What instruction is most appropriate in patient with trigeminal neuralgia to prevent triggering the pain?

Accepted Answer

Answer reason: Chewing on the unaffected side minimizes stimulation of the affected trigeminal nerve and helps prevent triggering severe facial pain. Cold stimuli can provoke attacks, warm compresses are not primary prevention, and oral hygiene should be performed gently rather than avoided.

Question 32

What is considered the fifth vital sign when taking vital signs of a client admitted with pancreatic cancer?

Accepted Answer

Answer reason: Pain is recognized as the fifth vital sign and should be routinely assessed, especially in clients with cancer.

Question 33

What is the primary consideration when caring for a patient with rheumatoid arthritis?

Accepted Answer

Answer reason: For rheumatoid arthritis, the foremost nursing priority is relief of pain and enhancement of comfort through rest, positioning, heat/cold, and joint protection. Surgery and education are important but not primary in routine care.

Question 34

The nurse is caring for a client with rheumatoid arthritis. The nurse knows that the client's symptoms will be most improved by?

Accepted Answer

Answer reason: Rheumatoid arthritis is characterized by morning stiffness that is relieved by heat and gentle movement; a warm shower on awakening reduces stiffness most effectively.

Question 35

A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client's vital signs that include?

Accepted Answer

Answer reason: Severe acute pain activates the sympathetic nervous system, leading to increased blood pressure along with elevated heart and respiratory rates. Fever is not expected unless infection is present.

Question 36

A client with rheumatoid arthritis has Sjogren's syndrome. The nurse can help relieve the symptoms of Sjogren's syndrome by?

Accepted Answer

Answer reason: Sjögren's syndrome causes dry eyes and mouth due to reduced exocrine secretions. Artificial tears/eyedrops relieve ocular dryness, unlike joint heat, analgesics, or meal frequency.

Question 37

What is the appropriate position for a patient after mastectomy?

Accepted Answer

Answer reason: After mastectomy, the affected arm should be elevated (often in semi-Fowler’s) to promote lymphatic drainage, reduce edema, and protect the incision. Lying on the affected side, left lateral, or prone are not recommended.

Question 38

What is the appropriate postoperative position after a stapedectomy?

Accepted Answer

Answer reason: After a stapedectomy, the client should be positioned with the operative ear up to avoid pressure and prosthesis displacement; therefore place on the unaffected side. Prone, affected side, or vague lateral positions are inappropriate.

Question 39

A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?

Accepted Answer

Answer reason: In vaso-occlusive sickle cell crisis, elevate the head to improve oxygenation and keep legs extended to promote venous return; avoid knee flexion that can impede circulation. Semi-Fowler's with legs extended is best.

Question 40

A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she?

Accepted Answer

Answer reason: Layering clothing conserves body heat safely for clients with hypothyroidism. External heat sources such as electric blankets, heating pads, or frequent hot baths increase risk of burns and vasodilation/hypotension and are not recommended.

Question 41

Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?

Accepted Answer

Answer reason: Warmth decreases morning joint stiffness and pain in rheumatoid arthritis; holding a warm cup provides local heat to the hands and improves comfort and function.

Question 42

A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to?

Accepted Answer

Answer reason: Cool, humidified air soothes inflamed mucosa, loosens/thins secretions, and decreases laryngeal edema and spasm in croup. It is not for oxygen delivery, fever control, or water-loss prevention.

Question 43

To decrease the likelihood of seizures and visual hallucinations in a client with alcohol withdrawal, the nurse should?

Accepted Answer

Answer reason: Alcohol withdrawal care includes minimizing environmental stimulation to reduce agitation, seizures, and perceptual disturbances. A quiet room with dim lighting decreases triggers, whereas darkness or continuous bright light and media increase stimulation.

Question 44

What should be the temperature of water used for cold sponging?

Accepted Answer

Answer reason: Cold sponging uses cool water around 65–75°F to promote heat loss; 70°F is appropriate. The other options are too warm or freezing.

Question 45

Jordin is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client?

Accepted Answer

Answer reason: Pruritus from jaundice causes intense itching; keeping nails short and smooth reduces scratching, skin breakdown, and infection risk. Vitamin K addresses coagulopathy, not itching; decreasing protein is not indicated; applying pressure for IM injections is unrelated.

Question 46

A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should?

Accepted Answer

Answer reason: Supporting and elevating the scrotum reduces dependent edema and discomfort. Ice or heat are inappropriate, and analgesics do not address the edema directly.

Question 47

The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is?

Accepted Answer

Answer reason: Pain is widely recognized as the fifth vital sign and should be assessed routinely with other vital signs.

Question 48

The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client?

Accepted Answer

Answer reason: Client teaching for TENS includes monitoring the skin under electrodes and reporting irritation or burns. Lotions/creams should not be used under electrodes, and TENS is not safe on all body areas. Electrocution warning is inaccurate.

Question 49

The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to?

Accepted Answer

Answer reason: At 48 hours post-hemorrhoidectomy, warm sitz baths after each bowel movement reduce pain, cleanse the area, and promote healing. High-fiber intake is encouraged, ice packs are mainly for the first 24 hours, and routine daily laxatives are not preferred over stool softeners and fiber.

Question 50

A client with cancer develops xerostomia. The nurse can help alleviate the discomfort the client is experiencing associated with xerostomia by?

Accepted Answer

Answer reason: Xerostomia is dry mouth; artificial saliva directly moistens the oral mucosa and relieves discomfort. Analgesics and joint splinting are unrelated, and offering hard candy (not specified as sugarless) is less appropriate than saliva substitute.

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