S3 Exam 2 Practice Questions

A client taking levothyroxine for hypothyroidism reports fatigue and wearing a sweater regularly despite warm weather. Which of the following actions would the nurse take? Select all that apply.

A) Obtain vital signs.

B) Check body temperature.

C) Review medication record.

D) Measure intake and output.

E) Assess swallowing reflex.

A) Obtain vital signs.

B) Check body temperature.

C) Review medication record.

Rationale: Fatigue is commonly associated with hypothyroidism. Wearing warmer clothing even in warm weather may indicate a cold intolerance, which is a sign of hypothyroidism. Although the client is taking levothyroxine, it may not be as effective as needed, or there may have been doses that were missed or held. Therefore the nurse will check vital signs (Choice A), body temperature (Choice B), and the medication record (Choice C) to assess possible reasons for these changes and likely contact the health care provider for ongoing evaluation of symptoms and appropriateness of drug therapy. There is no need to measure intake and output (Choice D), nor to assess for a swallowing reflex (Choice E) at this time.

The nurse is caring for a client 4 hours after a total thyroidectomy. Which assessment finding would alert the nurse to a possible complication?

A) Temperature 98.0°F (36.7°C)

B) Absence of bowel movement

C) Report of tingling around the mouth and in the hands

D) Small amount of serosanguineous drainage on dressing

C) Report of tingling around the mouth and in the hands

Rationale: Experiencing a tingling sensation after surgery can be indicative of hypocalcemia, a potential complication of total thyroidectomy that must be recognized and corrected (Choice C). Other findings such as a slightly reduced temperature (Choice A), absence of bowel movement (Choice B), and a small amount of serosanguineous drainage on the dressing (Choice D) are expected after surgery and do not indicate the possibility of a postoperative complication

A client has been diagnosed with hypothyroidism. Which instruction would the nurse include about hormone replacement therapy?

1. Explain that this type of therapy will shrink a goiter.

2. Take medication before bed with an evening snack.

3. Report chest discomfort and palpitations to the health care provider.

4. Hormone replacement therapy is stopped after a euthyroid state is achieved.

3) Report chest discomfort and palpitations to the health care provider.

Rationale: Palpitations and chest discomfort can indicate a serious reaction to hormone replacement therapy, especially if the client has a history of cardiac concerns (Choice C). These should be reported to the health care provider. This therapy does not shrink a goiter (Choice A). It should be taken early in the morning, not at night (Choice B). It is lifelong therapy, not temporary therapy that is given until the client achieves a euthyroid state (Choice D).

Which of the following symptoms in a client with untreated hypothyroidism would require the nurse to intervene imme-diately? Select all that apply.

1. Sodium 149 mEq/L (149 mmol/L) (Reference range:
   136-145 mEq/L [136-145 mmol/L])

2. Blood pressure 130/88 mm Hg

3. Blood glucose 118 mg/dL (6.6 mmol/L) (Reference range:
   74-106 mg/dL [4.1-5.9 mmol/L])

4. Temperature 97.2°F (36.2°C)

5. Decreased level of consciousness

4) Temperature 97.2°F (36.2°C)

5) Decreased level of consciousness

Rationale: The nurse will intervene immediately when there are signs of myxedema coma in a client with untreated hypothyroidism. These signs include hyponatremia, hypothermia, and decreased level of consciousness. Other symptoms may include hypotension, bradycardia, and respiratory depression. The temperature of 97.2°F (36.2°C) indicates hypothermia (Choice D), and the decreased level of consciousness is concerning (Choice E); these findings require immediate intervention by the nurse. The sodium level of 149 mEq/L (149 mmol/L) is normal (Choice A). The blood pressure (Choice B) and the blood glucose (Choice C) are minimally high but not concerning and do not require immediate intervention. Hypotension and hypoglycemia are more commonly found in clients who experience myxedema coma.

The nurse hears a client who is scheduled to receive radioactive iodine therapy discussing treatment with the client's partner. Which client statement would require the nurse to provide further teaching?

1. "We shouldn't share the same toothpaste tube."

2. "I am going to stay 6 feet away from anyone who is preg-nant."

3. "It will be necessary to work from home for a month after therapy."

4. "Remind me to flush the toilet two to three times after each use when I am home."

3) "It will be necessary to work from home for a month after therapy."

Rationale: The nurse will intervene when the client states that working from home will be required for a month (Choice C); usually clients are able to return to work after a week following therapy. The client is accurate in stating that toothpaste tubes should not be shared (Choice A), that it is important to stay 6 feet away from people who are pregnant (Choice B), and to flush the toilet two to three times after each use (Choice D); these statements do not require further teaching from the nurse.

Which statement made by the client alerts the nurse to the possibility of hypothyroidism?

1. “My grandmother had thyroid problems.”

2. “I seem to feel the heat more than other people.”

3. “Food just doesn’t taste good without a lot of salt.”

4. “I am always tired, even when I get 10 or 12 hours of sleep.”

4) “I am always tired, even when I get 10 or 12 hours of sleep.”

Clients with hypothyroidism usually feel tired or weak and often report an increase in time spent sleeping, sometimes up to 14 to 16 hours per day. Thyroid problems are very common among women and do not demonstrate a specific pattern of inheritance. Clients with hypothyroidism have a slow metabolism and have difficulty keeping warm. Salt craving is not a symptom of hypothyroidism.

Which changing trends in a client’s serum laboratory values indicate to the nurse that thyroid hormone replacement therapy for hypothyroidism is effective?

1. Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels

2. Declining thyroid hormone (TH) levels; rising thyroid-stimulating hormone (TSH) levels

3. Rising thyroglobulin (Tg) levels; declining thyrotropin receptor antibody (TRAb) levels

4. Declining thyroglobulin (Tg) levels; rising thyrotropin receptor antibody (TRAb) levels

1) Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels

Drug therapy for hypothyroidism hormone replacement therapy with synthetic thyroid hormones, which would result in rising TH levels. As these levels rise, the negative feedback loop, which tries to stimulate the thyroid gland to produce TH would be suppressed, causes declining TSH levels. Thyroglobulin levels are related to active thyroid tissue. In hypothyroidism, these levels are low and drug therapy does not increase them. TRAbs are not a cause of hypothyroidism and do not develop with drug therapy.

The nurse is caring for a client with severe hypothyroidism. When the client is difficult to around and has a heart rate of 48 beats/minute, which action will the nurse to take first?

1. Assess blood pressure.

2. Apply oxygen by mask.

3. Contact the health care provider.

4. Activate the Rapid Response Team.

2) Apply oxygen by mask.

The most common cause of death with severe hypothyroidism is respiratory failure with decreased gas exchange. The nurse would apply oxygen first and then activate the Rapid Response Team. Other actions can be taken subsequently.

A client with hypothyroidism is prescribed thyroid hormone replacement therapy (HRT). Which precaution will the nurse communicate?

1. “Avoid over-the-counter medications unless prescribed by your provider.”

2. “Increase the amount of fiber in your diet to prevent the side effect of constipation.”

3. “Stop this drug immediately if you discover you are pregnant.”

4. “If you miss a dose, double your next day’s dose.”

1) “Avoid over-the-counter medications unless prescribed by your provider.”

The amount of drug in synthetic thyroid hormone tablets is very small and many other foods and drugs interfere with its absorption. The client is instructed to not take over-the-counter medications without approval from the provider. Fiber greatly interferes with the drug’s absorption and is not to be taken with or within 4 hours of HRT. In addition, the drug does not cause constipation. Thyroid HRT must continue during pregnancy. The therapy works best when blood levels are maintained. The client is taught to take the forgotten drug as soon as it is remembered and not to double the next day’s dose.

For which new-onset symptom associated with thyroid hormone replacement therapy (HRT) will the nurse teach a client to report to the primary health care provider?

1. Anorexia

2. Runny nose

3. Hand tremors

4. Calf muscle cramping

3) Hand tremors

Hand tremors are an indication of HRT toxicity with increased central nervous system stimulation. The dose must be decreased to prevent more serious neurologic and cardiac toxicities. Anorexia, runny nose, and calf muscle cramping are not side effects anticipated with HRT.

A client with Graves disease has a goiter. Which teaching will the nurse provide when the client says, “Why do I have this thing”?

1. The low circulating levels of thyroid hormones stimulates the feedback system and triggers the anterior pituitary gland to secrete more thyroid-stimulating hormone, which increases the numbers and size of glandular cells in the thyroid gland.

2. The autoantibodies stimulate the inflammatory and immune responses to increase the number of white blood cells circulating in the thyroid gland, which increases tissue size without increasing the number of glandular cells.

3. The autoantibodies stimulate blood vessel growth and blood storage within the thyroid gland, increasing its overall size.

4. The excessive autoantibodies bind to the thyroid-stimulating hormone receptor sites, which increases the number and size of glandular cells in the thyroid gland.

4) The excessive autoantibodies bind to the thyroid-stimulating hormone receptor sites, which increases the number and size of glandular cells in the thyroid gland.

Graves disease is an autoimmune disorder in which antibodies (thyroid-stimulating immunoglobulins [TSIs]) are made and attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid tissue. The thyroid gland responds by increasing the number and size of glandular cells, which enlarges the gland, forming a goiter and overproduces thyroid hormones (thyrotoxicosis).

Which action does the postanesthesia care unit (PACU) nurse perform when caring for a client who has just arrived after a total thyroidectomy?

1. Assessing the wound dressing for bleeding

2. Administering morphine for pain

3. Monitoring oxygen saturation

4. Maintaining the neck position

3) Monitoring oxygen saturation

Airway assessment and management is always the first priority with every client, especially for a client who has had surgery that involves potential bleeding and edema near the trachea. Assessing the wound dressing for bleeding is a high priority, which is performed next after assessing airway and breathing. Pain control is important, but can be addressed after airway assessment. The neck position should be maintained to avoid tension on the incision.

The nurse reviews the vital signs of a client diagnosed with Graves disease and notes that the client’s temperature is 99.6°F (37.6°C). After notifying the primary health care provider, what is the nurse’s next action?

1. Administer aspirin.

2. Activate the Rapid Response Team.

3. Observe for the presence of chills.

4. Assess cardiac status.

4) Assess cardiac status.

Graves disease is manifested by symptoms of hyperthyroidism and increased metabolic rate, including fever. The nurse must next assess the client’s cardiac status as atrial fibrillation or other dysrhythmias may have developed. If the client has a cardiac monitor, the nurse needs to check for any dysrhythmias. Administering aspirin is contraindicated. Activating the Rapid Response Team is not needed at this time as no instability has been noted. Unlike with infection, temperature elevations in a client with hyperthyroidism are not associated with chills.

Which statement made by a client who is undergoing therapy with radioactive iodine (RAI) for Graves disease indicates a lack of understanding about the disorder and its treatment?

1. “It will be great to lose my “bug-eyed” appearance.”

2. “If this treatment works, maybe I will stop sweating all the time.”

3. “I hope I don’t gain too much weight when my thyroid function is normal.”

4. “Luckily, I have my own bathroom, so I won’t be exposing the rest of my family to radiation.”

1) “It will be great to lose my “bug-eyed” appearance.”

Although successful radioactive iodine (RAI) therapy for Graves disease results in reducing most physical symptoms, the exophthalmia does not respond to this therapy. Other measures, such as drug therapy targeted to the exophthalmos and not the hyperthyroidism and surgery to remove tissue from behind the eye, are needed to improve the eye appearance. All other client statements demonstrate accurate understanding of the disorder and its treatment.

.

Which assessment findings will the nurse expect to find in a client who has just been diagnosed with hypothyroidism? (Select all that apply.)

1. Pulse rate below 60 beats/min

2. Agitation and inability to sleep

3. Nonpitting edema of hands and feet

4. Decreased deep tendon reflexes

5. Warm, moist skin

1) Pulse rate below 60 beats/min

3) Nonpitting edema of hands and feet

4) Decreased deep tendon reflexes

Hypothyroidism slows the metabolism and function of all systems and the ones that are usually first noticed and can lead to life-threatening complications of the cardiac and central nervous systems. Thus, the heart rate is usually slower than 60 beats/min, and the deep tendon reflexes are decreased. Metabolites that are compounds of proteins and sugars called glycosaminoglycans (GAGs) build up inside cells, which increase the mucus and water, forming cellular edema that is nonpitting. The onset is so slow and insidious that clients may not even notice them until severe changes are present. Other assessment findings are not expected.

The nurse is planning to teach a community group about hyperthyroidism. Which teaching will the nurse include? (Select all that apply.)

1. Has a sudden onset of symptoms.

2. Most common form is Graves disease.

3. Can be diagnosed by the presence of a goiter.

4. Produces symptoms of a hypermetabolic state.

5. Is much more common among women than among men.

2) Most common form is Graves disease.

4) Produces symptoms of a hypermetabolic state.

5) Is much more common among women than among men.

Hyperthyroidism increases the metabolism and function of all systems. The most common cause of hyperthyroidism is Graves disease, which is an autoimmune disorder, often occurring after an episode of thyroid inflammation leading to the production of autoantibodies (thyroid-stimulating immunoglobulins [TSIs]) that attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid gland. The increased stimulation of TSH receptors greatly increases thyroid hormone production. All thyroid problems are from five to ten more common among women than men. The onset is so slow and insidious that clients may not even notice them until severe changes are present. A goiter only indicates a thyroid problem and can occur with both hypothyroidism and hyperthyroidism. Exposure to ionizing radiation can induce hypothyroidism, not hyperthyroidism.

Which items are most important for the nurse to ensure are in the room when a client returns from having a thyroidectomy? (Select all that apply.)

1. Calcium gluconate

2. Emergency tracheotomy kit

3. Hypertonic saline

4. Oxygen

5. Suction

1) Calcium gluconate

2) Emergency tracheotomy kit

4) Oxygen

5) Suction

Calcium gluconate needs to be available at the bedside to treat hypocalcemia and tetany that might occur if the parathyroid glands have been injured during surgery. Equipment for an emergency tracheotomy must be kept at the bedside in the event that hemorrhage or edema occludes the airway. Oxygen always needs to be at the bedside and especially for the thyroidectomy client who may experience respiratory distress from swelling or damage to the laryngeal nerve leading to spasm. It is also important to have suction available at the client’s bedside because of the risk for increased secretions. Hypertonic saline is not necessary for this client. This client is not expected to have hyponatremia after surgery.

Which action immediately after a hypophysectomy will the nurse instruct a client to avoid? (Select all that apply.)

A.      Talking

B.     Coughing 

C.     Deep breathing

D.     Using dental floss

E.      Bending at the waist 

B.     Coughing 

E.      Bending at the waist 

Coughing early after surgery increases intracranial pressure (ICP) and pressure in the incision area which may lead to a leak of cerebrospinal fluid. Bending at the waist also increases ICP. Talking has no harmful effects. Clients are taught to avoid toothbrushing right after this procedure (which could injure the incision line) and are encouraged to floss instead.

The nurse has just received report on a group of clients. Which client will the nurse see first?

A.      Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L) 

B.     Client with hyperaldosteronism who has a serum potassium of 3.0 mEq/L (3.0 mmol/L)

C.     Client with diabetes insipidus who has a dose of desmopressin due

D.     Client with pituitary adenoma who is reporting a severe headache

A.      Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L)  Correct

The nurse first attends to the client with adrenal insufficiency who has a blood glucose level of 36 mg/dL (2.0 mmol/L). The client’s condition is considered a medical emergency and must be assessed and treated immediately. All other clients can be seen subsequently.

The nurse is caring for a client with Cushing syndrome who throws a water pitcher and screams, “I hate feeling this way!” Which nursing response is appropriate?

A.      “I will have your primary health care provider order a psychiatric consult.”

B.     “You are likely feeling this way because of your high hormone levels.” 

C.     “I think you are experiencing this because you are scared of a chronic disease.”

D.     “You must learn to control your feelings and this sensation will pass soon.”

B.     “You are likely feeling this way because of your high hormone levels.” 

Changes in blood cortisol levels can cause the client to show neurotic or psychotic behaviors. Explaining the reason for the feelings can be helpful. The nurse also needs to set boundaries for behavior. The client needs to know that these behavior changes do not indicate a psychiatric disorder and will resolve when therapy results in lower and more steady blood cortisol levels. The feelings do not originate from fear of a chronic disease, and telling the client to control their feelings is inappropriate.

In collaboration with the registered dietitian nutritionist, which dietary alterations will the nurse teach a client with Cushing disease to make?

A.      High protein, high carbohydrate, and low potassium

B.     Low carbohydrate, high calorie, and low sodium

C.     Low protein, high carbohydrate, and low calcium

D.     High carbohydrate, low potassium, and fluid restriction

B.     Low carbohydrate, high calorie, and low sodium 

The client with Cushing disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of total calories and carbohydrates to prevent or reduce the degree of hyperglycemia. The sodium retention causes water retention and hypertension. Clients are encouraged to moderately restrict sodium intake. Other choices are inappropriate.

The nurse is caring for a client who had a transsphenoidal hypophysectomy yesterday. Which finding requires the nurse to notify the primary health care provider immediately?

A.      Nasal drainage that tests negative for glucose

B.     Dry lips and oral mucosa on examination

C.     Client report of a headache and stiff neck 

D.     Urine specific gravity of 1.016

C.     Client report of a headache and stiff neck 

Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client’s care. The finding requires the nurse to immediately notify the primary health care provider. Nasal drainage that tests negative for glucose is normal, expected, and not significant. Dry lips and mouth are not unusual after surgery. A urine specific gravity of 1.016 is within normal limits.

The nurse is monitoring laboratory values for a client with adrenal insufficiency undergoing IV therapy with hydrocortisone. Which finding demonstrates that

treatment has been effective? (Reference ranges: sodium = 136-145 mEq/L

[mmol/L]; potassium = 3.5-5.0 mEg/L [mmol/LI)

1. Serum sodium 150 mEq/L (mmol/L); serum potassium 7.16 mEq/L (mmol/L)

2. Serum sodium 138 mEq/L (mmol/L); serum potassium 4.2 mEq/L (mmol/L)

3. Serum sodium 122 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)

4. Serum sodium 118 mEa/L (mmol/L); serum potassium 6.7 mEa/L (mmol/L)

2) Serum sodium 138 mEq/L (mmol/L); serum potassium 4.2 mEq/L (mmol/L)

Rationale: With adrenal hypofunction, reduced levels of cortisol and aldosterone decrease serum sodium levels below normal (hyponatremia) and increase serum potassium levels above normal (hyperkalemia) (Choice B). Adequate drug therapy with hormone replacement is expected to return these electrolytes back to their normal ranges (sodium, 135–145 mEq/L [mmol/L]; potassium, 3.5–5.0 mEq/L [mmol/L]). Choice A indicates hypernatremia and hyperkalemia. Choice C indicates hyponatremia and hypokalemia. Choice D indicates severe hyponatremia and hyperkalemia.

The nurse is caring for a client with Cushing syndrome who must remain on continued glucocorticoid therapy for another health problem. Which intervention would the nurse include when designing the plan of care?

1. Increase intake of sodium.

2. Encourage drinking extra fluids.

3. Secure IV access with nonadhesive bandaging.

4. Massage areas where skin is under pressure.

3) Secure IV access with nonadhesive bandaging.

Rationale: The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured. Using nonadhesive methods to secure an IV access protects tissue integrity (Choice C). The client prescribed glucocorticoid usually has concerns with sodium retention and is on a salt-restricted diet, rather than a diet that needs an increase in sodium intake (Choice A). Extra fluids would not be encouraged (Choice B) as clients with Cushing syndrome are at risk for fluid volume excess. An area where skin is under pressure should never be massaged (Choice D); this can compromise tissue integrity and cause skin breakdown.

Which features will the nurse expect to be present in a client who has long-term chronic obstructive pulmonary disease? (Select all that apply.)

A.      Poor gas exchange from decreased alveolar surface area 

B.     Increased anteroposterior chest diameter from air-trapping 

C.     Arterial blood gas value with increased PaO₂ level

D.     Hypercapnia from retained PaCO₂ 

E.      Respiratory acidosis with a low pH 

A.      Poor gas exchange from decreased alveolar surface area Correct

B.     Increased anteroposterior chest diameter from air-trapping Correct

D.     Hypercapnia from retained PaCO₂ Correct

E.      Respiratory acidosis with a low pH Correct

Gas exchange is decreased by the increased work of breathing and the loss of alveolar tissue. Although some alveoli enlarge, the overall functional area available for gas exchange is decreased. The client also has a low arterial oxygen (PaO₂) level because it is difficult for oxygen to move from diseased alveoli into the blood. Chronic retention of carbon dioxide increases the PaCO₂ (hypercapnia) and results in respiratory acidosis. The anteroposterior chest diameter increases from air trapping.

Which client statement about using an aerosol inhaler for asthma management indicate understanding of this drug delivery system to the nurse? (Select all that apply.)

A.      “If I use a spacer, I don’t have to wait a minute between the two puffs.”

B.     “If the spacer makes a whistling sound, I am breathing in too rapidly.” 

C.     “Rinsing my mouth after using the inhaler and then swallowing the rinse ensures I will get all of the drug.”

D.     “When I suspect the canister is close to empty, I will shake it to check how much is left.”

E.      “I will hold my breath for at least 10 seconds after inhaling the drug.” 

B.     “If the spacer makes a whistling sound, I am breathing in too rapidly.” 

E.      “I will hold my breath for at least 10 seconds after inhaling the drug.” 

Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used. The client is instructed to hold the breath for at least 10 seconds. The client must wait 1 minute between puffs regardless of the method of delivery of the medication. The client is taught to rinse the mouth but not swallow the water. The mouth needs to be rinsed after using an inhaler with or without a spacer. This is especially important if the inhaled drug is a corticosteroid; rinsing will help prevent the development of an oral fungal infection. Shaking an inhaler helps ensure that the medication is dispersed and the same dose is delivered in each puff, it does not indicate how much drug remains in the inhaler. The client is taught to read the counter on the inhaler to know how many drug doses remain.

The nurse has just received report on a group of clients. Which client will the nurse assess first?

A.      A 62 year old with chronic obstructive pulmonary disease (COPD) being discharged with an oxygen saturation of 90%

B.     A 52 year old with end-stage pulmonary fibrosis and an oxygen saturation of 89%

C.     A 42 year old with lung cancer who needs an IV antibiotic administered before going to surgery

D.     A 22 year old with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min 

D.     A 22 year old with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min 

The client with CF with an elevated temperature and respiratory rate of 38 breaths/min is exhibiting signs of an exacerbation/infection and needs to be assessed first. The nurse will need to speak with the client who has COPD to help find a plan that will enable the client to obtain his or her prescribed medications. This may involve contacting case management or social services and discussing the discharge with the discharge health care provider. An oxygen saturation of 89% may be normal and expected for a client with end-stage pulmonary fibrosis. There is no indication that this client is in distress. The nurse can delegate administration of the IV antibiotic to another RN, or it could be administered before the client is brought to the operating room.

Which nursing action is the priority when preparing a client with cystic fibrosis (CF) for a lung transplantation procedure?

A.      Reminding the client to continue taking prescribed vitamin supplementation

B.     Teaching the client how to perform pulmonary muscle strengthening exercises 

C.     Using aseptic technique when assisting the client to perform pulmonary hygiene 

D.     Collaborating with the registered dietitian nutritionist to provide high-calorie, high-protein meals

B.     Teaching the client how to perform pulmonary muscle strengthening exercises 

Surgery for lung transplantation involves large “clam-shell” incisions that cut through ribs and muscle. This procedure is very painful and clients have a difficult time breathing deeply enough to wean from the ventilator. A critical factor in the outcome of the surgery and prevention of atelectasis and pneumonia in the new lungs is the strength of the muscles used for ventilation. These muscles must be strengthened before the transplantation.

Why will the nurse administer vitamin supplements to a client who has cystic fibrosis (CF)?

A.      Increased blood levels of vitamins enhance chloride transport activity.

B.     Clients are too fatigued to ingest sufficient vitamins and nutrients.

C.     High doses of vitamins can slow the progression of the disease.

D.     Steatorrhea causes a deficiency of fat-soluble vitamins. 

D.     Steatorrhea causes a deficiency of fat-soluble vitamins. 

The stool of clients with CF contains large amounts of fat (steatorrhea), which promotes loss of fat-soluble vitamins, leaving the client deficient of such vitamins and malnourished. Vitamins are important for general health and nutrition and play no role in the disease or its progression.

The nurse is caring for a client with emphysema who asks, “How is removing part of my lungs with lung volume reduction surgery going to help my breathing?” What is the appropriate nursing response?

A.      “This surgery makes room for the new lungs when a lung transplant is available.”

B.     “Breathing will be improved because diseased lung parts are removed and replaced with healthy parts.”

C.     “By removing only the over-inflated parts of the lungs, the air you breathe in will be going only to the lung areas that work best.” 

D.     “This surgery is preventive, because the parts of the lungs being removed are those that having the highest probability for developing cancer.”

C.     “By removing only the over-inflated parts of the lungs, the air you breathe in will be going only to the lung areas that work best.” 

Lung volume reduction surgery removes hyperinflated lung areas that contain only stale air and do not contribute to gas exchange. This ensures that respiratory effort results in better gas exchange in the remaining alveoli. Removing some volume also allows respiratory muscle contraction to be more effective. This surgery does not replace any lung tissue and is not performed as a precursor to lung transplantation. The hyperinflated areas are not more susceptible to cancer development than any other lung tissue.

The nurse is caring for a client with severe chronic obstructive pulmonary disease COPD that has new-onset increased fatigue, dependent edema, neck vein distension, and oral cyanosis. Which complication does the nurse suspect?

A.      Asthma

B.     Pneumonia

C.     Cor pulmonale 

D.     Lung cancer

C.     Cor pulmonale 

The client with long-term COPD develops higher pressures in pulmonary blood vessels making the right ventricle of the heart work harder to generate pressures that are high enough to perfuse the lungs. This persistent over-working of the right ventricle leads to right-sided heart failure that is not related to independent cardiac damage (cor pulmonale). This complication remains a constant risk for anyone with COPD. These symptoms are not related to asthma or pneumonia. Although some are also associated the lung cancer, they would appear slowly over time.

Which changes in arterial blood gas (ABG) values will the nurse expect in a client with long-term chronic obstructive pulmonary disease (COPD)?

A.      Increased pH; increased PaO₂; increased PaCO₂; increased bicarbonate level

B.     Increased pH; increased PaO₂; increased PaCO₂; decreased bicarbonate level

C.     Decreased pH; decreased PaO₂; decreased PaCO₂; decreased bicarbonate level

D.     Decreased pH; decreased PaO₂; increased PaCO₂; increased bicarbonate level 

D.     Decreased pH; decreased PaO₂; increased PaCO₂; increased bicarbonate level 

Hallmark changes in ABGs for long-term COPD is respiratory acidosis (increased arterial carbon dioxide [PaCO₂]); metabolic alkalosis (increased arterial bicarbonate) as compensation by kidney retention of bicarbonate (seen as an elevation of HCO₃^?2- although pH remains lower than normal); and lower-than-normal PaO₂ from poor gas exchange.

The nurse is discharging a client with chronic obstructive pulmonary disease to home. Which teaching is the priority regarding home oxygen therapy?

A.      Removing combustion hazards present in the home 

B.     Understanding the signs and symptoms of hypoxemia

C.     Correct performance when setting up the oxygen delivery system

D.     Demonstrating how to use a pulse oximetry device

A.      Removing combustion hazards present in the home 

The highest priority of education is that oxygen is highly combustible. The nurse must ensure that no open flames or combustion hazards will be present in a room where oxygen is in use. The oxygen delivery system in the home will be different than in the hospital. Therefore, this skill may be verified by the visiting nurse or company providing the oxygen. The client must be able to state signs and symptoms of hypoxemia, although safety is the priority. Pulse oximetry may be useful for monitoring the client’s oxygenation status and the visiting nurse or respiratory therapy partner can assess this

The nurse is admitting a client with a history of chronic obstructive pulmonary disease for a laparoscopic hysterectomy. Which nursing intervention in the priority to prevent infection?

A.      Assessing the client’s respiratory system every 8 hours

B.     Monitoring for signs and symptoms of pneumonia 

C.     Instructing the client to use a tissue when coughing or sneezing

D.     Ensuring the client remains in bed for a full 24 hours after surgery

B.     Monitoring for signs and symptoms of pneumonia 

The client with COPD is always at greater risk for development of a respiratory infection, especially after any surgery requiring anesthesia. The nurse would assess the client’s respiratory system at least every 2 hours. The client with COPD alone does not pose an infection risk to others, although everyone is urged to use a tissue to cover the mouth and nose when sneezing or coughing. Remaining in bed is avoided because it promotes atelectasis and pneumonia.

The nurse is teaching a client with chronic bronchitis. Which action will the nurse include to help mobilize secretions?

A.      Avoiding triggers that cause coughing

B.     Elevating the head of the bed 45 degrees

C.     Drinking at least 2 L of fluid daily 

D.     Assuming the tripod position as often as possible

C.     Drinking at least 2 L of fluid daily 

Clients with chronic bronchitis tend to have thick secretions. Hydration with at least 2 L of fluid daily thins tenacious (sticky) secretions, making them easier to expectorate. If health issues require fluid restriction, the client would attempt to consume the total amount permitted. Head of bed elevation may promote oxygenation and lung expansion, but does not promote secretion mobilization. Clients need to sit with both feet on the floor when performing controlled coughing. The tripod position is assumed during episodes of hypoxemia, but will not facilitate mobilization of fluid.

The nurse is teaching a client about a newly prescribed reliever drug inhaler for asthma. Which client statement indicates understanding of this therapy?

A.      “I will keep this inhaler with me at all times.” 

B.     “Reliever drugs are needed to prevent asthma attacks.”

C.     “At night, I will be sure to store the inhaler in a cool, dry place.”

D.     “If I forget a dose, I will use the inhaler as soon as I remember it.”

A.      “I will keep this inhaler with me at all times.”

The statement by the client that indicates a correct understanding of the instructions is that the emergency inhaler must be with the client at all times because asthma attacks cannot always be predicted. The inhaler is not to be stored at night; it needs to remain with the client for emergency use. Reliever drugs stop an attack and are used when needed, not on a schedule.

A client presents to the emergency department with extremely labored breathing and a history of asthma that is unresponsive to prescribed inhalers. What is the priority nursing action?

A.      Preparing the client for intubation

B.     Establishing IV access to give emergency medications

C.     Placing the client in a high-Fowler position, and starting oxygen 

D.     Asking the client how long they have had asthma and what triggered this attack

C.     Placing the client in a high-Fowler position, and starting oxygen 

With labored breathing, the client is most likely hypoxemic and the first priority is ensuring gas exchange by placing the client in a high-Fowler position and starting oxygen. The length of time the client has had asthma and the probably trigger for this attack are not important and will not affect how this attack is managed. Establishing IV access is important but not the first priority. Preparing a client for intubation is not needed unless all other methods to improve gas exchange are not effective.

How will the nurse categorize the level of asthma control for a client who reports usually waking at night with wheezing once weekly and needing to use the prescribed reliever inhaler to stop the episode?

A.      Controlled

B.     Partly controlled

C.     Minimally controlled

D.     Uncontrolled

B.     Partly controlled

The client meets the criteria for partly controlled asthma, which are that any of these symptoms occur one to two times per week:
 Daytime symptoms of wheezing, dyspnea, coughing
 Waking from night sleep with symptoms of wheezing, dyspnea, coughing
 Reliever (rescue) drug needed no more than twice weekly
 Activity limited or stopped by symptoms

The nurse is teaching a client who is newly diagnosed with asthma. Which information would the nurse include in the teaching?

1. Use the inhaled corticosteroid when experiencing dyspnea.

2. Bronchodilators are rapid acting, and side effects include tremors.

3. Immediately after using the inhaler, breathe out slowly.

4. When using a dry powder inhaler, inhale slowly.

2) Bronchodilators are rapid acting, and side effects include tremors.

Rationale: Bronchodilators are rapid acting and are often used as a reliever inhaler (Choice B). Expected side effects include tremors. An inhaled steroid works for long-term maintenance, not for relief of dyspnea (Choice A). Immediately after using an inhaler, clients are instructed to hold their breath, not to breathe out (Choice C). Holding the breath for a few seconds enhances delivery of the medication to the tissues. When using a dry powder inhaler, the client will breathe in quickly and deeply (Choice D). The force of the quick inhalation is what triggers the delivery of medication

The home health nurse is caring for a client with COPD who reports increased anxiety and dyspnea. Which nursing action will improve the client's breathing pattern?

1. Teach pursed-lip breathing technique.

2. Keep oxygen saturation greater than 90%.

3. Suggest using over-the-counter sleeping aids.

4. Discuss a high-calorie diet and nutritional needs.

1) Teach pursed-lip breathing technique.

Rationale: Pursed-lip breathing can improve a client’s breathing pattern by prolonging expiration and increasing airway pressure, which reduces air trapping (Choice A). Modifying the breathing pattern may decrease the sensation of dyspnea, as well as the associated anxiety. The client may have the feeling of dyspnea even with oxygen saturation greater than 90% (Choice B). Pursed-lip breathing is the appropriate action to address the breathing pattern and associated symptoms. The use of over-the-counter sleep aids is not recommended and is unrelated to the client’s breathing pattern (it could make the breathing pattern worse) (Choice C). While a high-calorie diet is often needed for clients with COPD, this is not going to address the client’s breathing pattern (Choice D).

The nurse is teaching a client about cystic fibrosis. Which of the following instructions would the nurse include? Select all that apply.

1. A sweat chloride test greater than 60 mmol/L is consistent with cystic fibrosis.

2. CF is a recessive disorder that affects the transport of chloride.

3. CF is a dominant disorder that affects the formation of alveoli.

4. Genetic testing is needed if two different sweat tests are positive.

5. CF is a recessive disorder affecting alpha -antitrypsin levels.

1) A sweat chloride test greater than 60 mmol/L is consistent with cystic fibrosis.

2) CF is a recessive disorder that affects the transport of chloride.

Rationale: The nurse will teach the client that cystic fibrosis is a genetic recessive disorder that affects the transport of chloride (Choice B). A sweat test greater than 60 mmol/L is consistent with a diagnosis of cystic fibrosis (Choice A). Although alpha1-antitrypsin deficiency is inherited in an autosomal pattern, this problem is associated with emphysema, not CF (Choice E). Alveolar formation is unaffected by CF (Choice C), and one sweat test is used for confirmation of CF (Choice D).

The nurse is caring for a client experiencing an acute exacerbation of asthma. Which assessment finding indicates the treatment is effective?

1. Wheezes become louder.

2. Coughing is nonproductive.

3. Breath sounds diminish.

4. Oxygen saturation is <90%.

1) Wheezes become louder.

Rationale: Wheezes that become louder indicate that airflow has improved and are a sign of effective treatment (Choice A). Diminished breath sounds (Choice C), the sudden absence of wheezing (Choice B), and decreased oxygen saturation (Choice D) are indications of complete airway obstruction, and tracheotomy is necessary

A client with COPD has all of the following arterial blood gas (ABG) changes from earlier today. Which change would alert the nurse to take immediate action?

1. pH from 7.21 to 7.20 (Reference range: 7.35-7.45)

2. HCO- remains the same at 31 mEq/L (Reference range: 22-26 mEq/L)

3. Paco, from 45 mm Hg to 68 mm Hg (Reference range: 35-45 mm Hg)

4. Pao, from 88mm Hg to 86 mm Hg (Reference range: 75-100 mm Hg)

3) Paco, from 45 mm Hg to 68 mm Hg (Reference range: 35-45 mm Hg)

Rationale: The rise in Paco2 represents acute hypercapnia, which could rapidly lead to respiratory failure (Choice C). Although the oxygen level has dropped slightly (Choice D), which is never good, it is the dramatic rise in carbon dioxide level that requires immediate action to determine the cause and intervene to prevent a worsening of the client’s condition. The decrease in pH supports the identification of hypercapnia, but this change alone does not warrant immediate action (Choice A). The bicarbonate level is unchanged (Choice B), which supports that the hypercapnia is an acute problem.

The nurse is caring for a client with cor pulmonale. Which of the following assessment findings are expected? Select all that apply.

1. Finger clubbing

2. Elevated temperature

3. Distended jugular veins

4. Peripheral edema

5. Exertional dyspnea

3) Distended jugular veins

4) Peripheral edema

5) Exertional dyspnea

Rationale: Cor pulmonale symptoms are those of right-sided heart failure. Expected assessment findings include distended jugular veins (Choice C), peripheral or dependent edema (Choice D), and exertional and increasing dyspnea (Choice E). Finger clubbing (Choice A) and elevated temperature (Choice B) are not findings expected with cor pulmonale.

The nurse is caring for a client 4 days post-lung transplant.

Which of the following management actions would the nurse anticipate? Select all that apply.

1. Corticosteroid therapy

2. Antirejection medications

3. High doses of oxygen therapy

4. Chest physiotherapy

5. Antibiotic therapy

2) Antirejection medications

4) Chest physiotherapy

5) Antibiotic therapy

Rationale: Postoperative care for a client receiving a lung transplant includes antirejection medications, chest physiotherapy, and antibiotic therapy (Choices B, D, and E). Corticosteroids are avoided for the first 10 to 14 days so that they do not impact the healing process (Choice A). High doses of oxygen are not always required, but oxygen therapy may be needed based on the client’s response (Choice C).

The nurse is assessing a client who is receiving in-home hospice care. Which of the following assessment data indicate signs of approaching death? Select all that apply.

1. Periods of apnea with alternating rapid breathing

2. No bowel movement for 2 days

3. Gurgling sound with inspiration

4. Heart rate 130 beats/min; blood pressure 80/40 mm Hg

5. Unable to lie still in the bed

1) Periods of apnea with alternating rapid breathing

3) Gurgling sound with inspiration

4) Heart rate 130 beats/min; blood pressure 80/40 mm Hg

5) Unable to lie still in the bed

Rationale: Periods of apnea that alternate with rapid breathing are referred to as Cheyne-Stokes respirations and are a sign of approaching death (Choice A). A gurgling sound, often referred to as the death rattle, can occur when death is approaching (Choice C). An elevated heart rate (130 beats/min) and low blood pressure (80/40 mm Hg), as well as restlessness (unable to lie still in bed), are also signs of approaching death (Choices D and E). While bowel function does decrease during the dying process, the client’s lack of bowel movement in a short time frame (2 days) does not indicate that death is impending (Choice B).

The nurse is caring for a client in hospice care who is experiencing dyspnea, with a respiratory rate of 30. Which of the following nursing interventions are appropriate? Select all that apply.

1. Direct a bedside fan toward the client's face.

2. Apply oxygen at 2L per nasal cannula.

3. Administer an anticholinergic sublingually.

4. Administer low-dose morphine orally.

5. Consult the provider for possible intubation.

1) Direct a bedside fan toward the client's face

2) Apply oxygen at 2L per nasal cannula.

3) Administer an anticholinergic sublingually

4) Administer low-dose morphine orally.

Rationale: It is appropriate for the nurse to direct a fan toward the client’s face as this is a comfort measure that can decrease the perception of dyspnea (Choice A). It is also appropriate to apply oxygen at the end of life regardless of the oxygen saturation (Choice B). Administering an anticholinergic can help to dry up secretions that contribute to dyspnea near death (Choice C). Administering morphine is the standard treatment for dyspnea near death (Choice D). It is not appropriate to consult the provider for possible intubation for a hospice client (Choice E).

The spouse of a client who has just died starts to cry and hug the client. Which of the following nursing responses are appropriate? Select all that apply.

1. Allow the spouse to grieve.

2. Ask the spouse not to touch the body.

3. State, "Don't be upset; they are in a better place"

4. State, "I am sorry this is happening"

5. Leave the spouse alone with the client.

1) Allow the spouse to grieve

4) State, "I am sorry this is happening"

Rationale: When a client dies, the family should be allowed to grieve (Choice A). This will look different in every situation as expressions of grief vary widely. Crying and touching the deceased person are common reactions to death and should not be suppressed (Choice B). The nurse who states “I am sorry this is happening” is showing empathy and acknowledging the grief response (Choice D). The nurse would not state, “Don’t be upset; they are in a better place.” This statement diminishes the way the spouse feels and ascribes the nurse’s belief system into the grieving process (Choice C). While the spouse may request some time alone with the deceased, the nurse should remain with the spouse unless this is requested (Choice E). Some family members do not want to be alone with the deceased.

The nurse is caring for a client with terminal dehydration.

The family wants the client to receive intravenous fluids.

Which nursing response is appropriate?

1. "Intravenous fluids will be a good addition to the plan of care."

2. "Intravenous fluids may increase the client's discomfort."

3. "Intravenous fluids may be started, but this may prolong life."

4. "Pain medication can be used to treat terminal dehydra-tion."

2) "Intravenous fluids may increase the client's discomfort."

Rationale: The nursing statement “Intravenous fluids may increase the client’s discomfort” is accurate and will provide education to the family (Choice B). Once the system has slowed down and the client is in a terminal dehydration status, administering fluid can increase discomfort and end-of-life dyspnea; as such, intravenous fluids are not a good addition to this client’s plan of care (Choice A). Intravenous fluids will not prolong life; however, they may increase discomfort (Choice C). Pain medications are used to manage pain and dyspnea, not terminal dehydration (Choice D). Terminal dehydration generally does not cause distress.

A client admitted to the hospital states, “Someone asked me to fill out an advance directive when I was admitted, but I was too stressed. What is that for?” How will the nurse respond?

1. “Advance directives are for those individuals who are critically ill.”

2. “Advance directives allow a client to convey health care wishes.”

3. “You will need to see a lawyer to complete advance directives.”

4. “You need to complete that paperwork before admission.”

2) “Advance directives allow a client to convey health care wishes.”

The nurse responds by stating that advanced directives allow a client to convey his or her wishes about health care. This best addresses the client’s comments. Most advance directives are in place before the client becomes severely ill. Many Americans do not have advance directives in place. Legal assistance is not necessary to complete them. Although completing paperwork pertaining to advance directives before admission would be ideal, any time is a good to do this.

A client with terminal lung cancer is receiving hospice care at home. Which nursing action will the RN manager ask the LPN/LVN to do?

1. Administer prescribed medications to relieve the client’s pain, shortness of breath, and nausea.

2. Clarify family members’ feelings about the meaning of client behaviors and symptoms.

3. Develop a plan for care after assessing the needs and feelings of both the client and the family.

4. Teach the family to recognize signs of client discomfort such as restlessness or grimacing.

1) Administer prescribed medications to relieve the client’s pain, shortness of breath, and nausea.

LPN/LVNs are educated to administer medications and monitor clients for therapeutic and adverse medication effects; the administration of prescribed medications to the client for pain, shortness of breath, and nausea is appropriate to delegate to the LPN/LVN. Clarifying family members’ feelings, developing a plan of care, and teaching the family to recognize signs of discomfort all require broader education and are appropriate for the RN practice level.

The family of a client who is unconscious and dying realizes that their mother will die soon. The client’s children are having a difficult time letting go. How will the nurse respond to the needs of this family?

1. “She would not want you to cry; she needs you to be strong.”

2. “She will soon be in a better place.”

3. “Things will be ok, just try to enjoy your time together.”

4. “This must be difficult for you.”

4) “This must be difficult for you.”

The nurse responds by stating, “This must be difficult for you.” This statement tells the family that the nurse is aware of their needs. The nurse knows to accept whatever the grieving person says about the situation, and must remain present, be ready to listen attentively, and guide gently. In this way, the nurse can help the bereaved prepare for the necessary reminiscence and integration of the loss. The client’s or family member’s pain of loss should never be minimized. Trite assurances such as saying, “She would not want you to cry” or “Things will be ok,” should be avoided. Such comments can be barriers to demonstrating care and concern. Never try to explain a client’s death or impending death philosophically or religiously because such statements are not helpful when the bereaved person has yet to express anguish or anger.

The daughter of a client who is dying states, “I don’t want my father to be uncomfortable.” How will the nurse respond?

1. “Do you want to talk to the bereavement nurse?”

2. “Your father will be closely monitored and cared for.”

3. “Your father will be sedated and comfortable.”

4. “We will send him to hospice when the time comes.”

2) “Your father will be closely monitored and cared for.”

The nurse responds by telling the daughter that her father will be closely monitored and cared for. This would reassure the daughter as well as provide support and comfort. The daughter’s comment does not require the expertise of a bereavement nurse. Also, asking if the daughter wants to talk to a bereavement nurse is a “yes-or-no” question, it is a nontherapeutic response and may shut off the dialog. The dying client is not typically sedated; clients are comfortable with as little or as much pain medication as needed. A goal is to keep the client alert and able to communicate. Telling the daughter that her father will be sent to hospice when the time comes does not address the daughter’s concern about her father’s comfort, and it closes the dialog.

A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention will the nurse implement?

1. Bring in the client’s favorite food.

2. Call the family to come in right away.

3. Administer intravenous hydration.

4. Offer ice chips.

4) Offer ice chips

The client who is dying should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and “dry mouth.” The client’s metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client’s case. Because the dying client’s metabolic needs have decreased, invasive procedures are not currently necessary.

.

Which condition, when assessed in a client who is dying, requires the nurse to take action?

1. Alternating apnea and rapid breathing

2. Anorexia

3. Cool extremities

4. Moaning

4) Moaning

Moaning indicates pain and requires pain medication. Alternating apnea and rapid breathing, anorexia, and cool extremities are normal assessment findings in the client who is dying.

The nurse is coordinating interprofessional palliative care interventions for the client who is dying. Which goal is the nurse seeking to meet?

1. Avoiding symptoms of client distress

2. Ensuring an expedited death

3. Meeting all of the client’s needs

4. Facilitating a peaceful death for the client

4) Facilitating a peaceful death for the client

Facilitating a peaceful death for the client is one of the goals of palliative care. Symptoms of distress cannot be avoided but can be controlled. Expedited death is not a goal of palliative care. Identifying client needs is a goal of palliative care, but it is not always possible to meet all of the client’s needs (e.g., to prevent death or lengthen life).

A client has died after a long hospital stay. The family was present at the time of the client’s death. Which postmortem nursing action is appropriate?

1. Asking the family if they wish to help wash the client

2. Asking the family to leave during post-death care

3. Raising the head of the bed and opening the client’s eyes

4. Removing dentures and any prosthetics

1) Asking the family if they wish to help wash the client

The nurse may ask the family if they wish to be involved in washing the client after the client’s death. The family should be allowed to grieve at the bedside of the client. The head of the bed should be flat, and the client’s eyes closed. The client’s dentures and prosthetics should be replaced, not removed.

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?

1. “Do you believe in God?”

2. “Tell me about religion in your life.”

3. “What gives you purpose in life?”

4. “Where have you been attending church?”

3) “What gives you purpose in life?”

The most accurate data about the client’s spirituality would come from the question, “What gives you purpose in your life?” Spirituality arises from whatever or whoever provides the client ultimate purpose and meaning. It is not necessarily God, but it could be. It could be the client’s definition of a higher power. The client may not believe in God and may find an inquiry about believing in God offensive and judgmental. Religion is considered by many people to be affiliation or membership in a faith community. Members of such a community may support the client if the client is a member, but this is not the best way to determine the client’s spirituality. Church attendance is one way some individuals express their religion, but it does not necessarily define a person’s spirituality; asking about church could put the client on the defensive.

A client who is dying is having difficulty swallowing oral medications. Which intervention will the nurse implement for this client?

1. Ask the pharmacy to substitute intramuscular (IM) equivalents for the medications.

2. Ask the provider if the medications can be discontinued or substituted.

3. Crush the pills, open the sustained-release capsules, and mix them with a spoonful of applesauce.

4. Do not administer the medications and document: “Unable to swallow.”

2) Ask the provider if the medications can be discontinued or substituted.

The nurse will contact the provider to ask if the medications can be discontinued or substituted. Since the client is in the dying process, he or she may no longer require some of the medications prescribed, and other routes may be available for medications that will promote comfort. The IM route is almost never used for clients at the end of life because this method is invasive and painful, and can cause infection. Although some pills may be crushed, sustained-release capsules should not be taken apart and their contents administered directly. The client may still need the medications prescribed for comfort; withholding them could cause discomfort throughout the dying process.

A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order will the nurse implement first?

1. Albuterol solution per nebulizer

2. Morphine sulfate sublingually as needed

3. Oxygen 2 to 6 L/min per nasal cannula

4. Prednisone elixir 10 mg orally

2) Morphine sulfate sublingually as needed

Morphine sulfate is the standard treatment for the dyspneic client near death. Albuterol, oxygen, and steroids may be useful but should be used as adjuncts to therapy with morphine

The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the assistive personnel to visit?

1. Advanced cirrhosis of the liver and just called the hospice agency reporting nausea

2. Aggressive brain tumor and needs daily assistance with ambulation and bathing

3. Inoperable lung cancer and considering whether to have radiation and chemotherapy

4. Prostate cancer with bone metastases and new-onset leg weakness and tingling

2) Aggressive brain tumor and needs daily assistance with ambulation and bathing

Assisting clients with activities of daily living such as ambulation and bathing is a common role for assistive personnel working in home health or hospice agencies. Assessing and acting upon a new symptom (nausea), helping clients make decisions, and evaluating a new-onset symptom all require more complex assessment skills and interventions within the RN scope of practice.

The nurse on an inpatient hospice unit received the change-of-shift report. Which client does the nurse assess first?

1. A 26 year old with metastatic breast cancer experiencing pain rated at 8 (0-10 scale) and anxiety.

2. A 30 year old with AIDS-associated dementia and agitation asking for assistance calling family members.

3. A 62 year old with lung cancer who has cool, clammy, dusky skin and blood pressure of 64/20 mm Hg.

4. A 70 year old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations.

1) A 26 year old with metastatic breast cancer experiencing pain rated at 8 (0-10 scale) and anxiety.

Management of pain is the priority goal for hospice care, so decreasing this client’s pain and anxiety should be the first action. The client with AIDS needs rapid assistance but is the second priority for the nurse in this scenario. The client with lung cancer and colon cancer are exhibiting normal signs and symptoms associated with dying.

A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client’s comfort?

1. Administers nutrition and fluids through a nasogastric tube.

2. Explains to the family that aspiration may be a concern.

3. Obtains a provider order to initiate an IV line.

4. Teaches the family how to provide oral care.

4) Teaches the family how to provide oral care.

Because the oral mucosa will become dry, the initial action taken by the nurse would be to teach the family members how to moisten the lips and mouth. Although fluids can be given through a nasogastric tube and through an IV line, these are generally considered to increase discomfort by prolonging the client’s suffering. Aspiration is not a concern in terminally ill clients, because fluids are not given orally to clients with decreased swallowing.

A client who is dying cannot swallow and is accumulating audible mucus in the upper airway (death rattles). These noises are upsetting to family members. What nursing action is appropriate?

1. Assist the family in leaving the room so that they can compose themselves.

2. Place the client in a side-lying position so secretions can drain.

3. Position the client in a high-Fowler position to minimize secretions.

4. Use a Yankauer suction tip to remove secretions from the client’s upper airway.

2) Place the client in a side-lying position so secretions can drain.

Placing the client in a side-lying position to facilitate the draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease. Asking the family to leave at this important time is not appropriate. Placing the client in a high-Fowler position is ineffective in helping the client who has lost the ability to swallow and increases the danger of choking and aspiration. Oropharyngeal suctioning is not recommended for removing secretions because it is ineffective and may even agitate the client.

In which newly admitted client situations does the nurse initiate a conversation about advance directives? (Select all that apply.)

1. A client with a non–life-threatening illness

2. A person who currently has advance directives

3. The client with end-stage kidney disease

4. The comatose client who was injured in an automobile crash

5. The laboring mother expecting her first child

1) A client with a non–life-threatening illness

2) A person who currently has advance directives

3) The client with end-stage kidney disease

5) The laboring mother expecting her first child

All clients who are hospitalized need to be asked about advance directives by the nurse when they are admitted to a hospital. This is a requirement of the Patient Self-Determination Act. Many nurses feel uncomfortable discussing advance directives with “healthy” clients, but the circumstances of admission do not relieve the nurse of this responsibility. The client with preexisting advance directives still needs to be questioned; it is possible that the client’s wishes have changed since the documents were established. Clients with potentially life-threatening diseases or conditions should establish advance directives while they can do so. The comatose client is not considered capable of making decisions about his or her wishes concerning advance directives.

The nurse is caring for a client who is actively dying. What nursing action is appropriate? (Select all that apply.)

1. Use moist swabs to keep the mouth and lips moist.

2. Place warm blankets on the client to keep them warm.

3. Make sure the room is well-lit.

4. Encourage the client to eat ice chips and drink as much as possible.

5. Do not encourage the client to stay awake.

6. Offer to insert a Foley catheter for comfort.

1) Use moist swabs to keep the mouth and lips moist.

5) Do not encourage the client to stay awake.

6) Offer to insert a Foley catheter for comfort.

When caring for a client actively dying, the skin may become cold and mottled. Do not apply heating blankets. Using moist swabs will help to keep the client’s mouth and lips more comfortable. The room should be dimly lit, with minimal noise and stimulation. The client should be offered ice chips or drink but do not force to drink as much as possible. Allow the client to rest, do not force them to stay awake. The nurse can offer a Foley catheter for comfort.

The nurse is teaching a class on advance directives. What will the nurse include? (Select all that apply.)

1. Advance directives are the same from state to state.

2. A durable power of attorney for health care is the same as a durable power of attorney for one’s health care.

3. A living will identify health care wishes regarding end-of-life treatment.

4. A health care proxy can only make decisions once a person no longer has their own ability to make decisions.

5. In order to make a health care decision, a person much be totally oriented.

6. A living will contains funeral directives as well as last wishes for the family.

3) A living will identify health care wishes regarding end-of-life treatment.

4) A health care proxy can only make decisions once a person no longer has their own ability to make decisions.

Advance directives vary from state to state. While all have similarities, each state is unique. A durable power of attorney for health care is not the same as a durable power of attorney for finances. This can be the same person—but must be defined specifically for both roles. A living will identifies would an individual would (or would not) want when he or she is near death. A living will contains information specific to artificial ventilation, nutrition or hydration, and resuscitation directives. It does not contain funeral directives or last wishes for family. In order to make health care decisions, a person does not need to be totally oriented. However, they must be able to receive information and then evaluate, deliberate, and manipulate the information as well as communicate a treatment preference.

A nurse is preparing to assess a preschooler.

Which of the following actions should the urse take to prepare the child?

1. Allow the child to role-play using miniature equipment.

2. Use medical terminology to describe what will happen.

3. Separate the child from the caregiver during the examination.

4. Keep medical equipment visible to the child.

1) Allow the child to role-play using miniature equipment.

A nurse is checking the vital signs of a 3-year-old child during a well-child visit. Which of the following findings should the nurse report to the provider?

1. Temperature 37.2° C (99.0° F)

2. Heart rate 106/min

3. Respirations 30/min

4. Blood pressure 88/54 mm Hg

3) Respirations 30/min

A nurse is providing teaching to the caregiver of a preschool-age child about methods to promote sleep.

Which of the following statements by the caregiver indicates an understanding of the teaching?

1. "I will sleep in the bed with my child if they wake up during the night."

2. "I will let my child stay up an additional 2 hours on weekend nights."

3. "I will let my child watch television for 30 minutes just before bedtime each night."

4. 'I will keep a dim lamp on in my child's room during the night."

4) 'I will keep a dim lamp on in my child's room during the night."

A nurse is preparing an education program for a group of caregivers of preschool-age children about promoting optimum nutrition. Which of the following information should the nurse include in the teaching?

1. Total fat intake should equal 20% of total daily caloric intake.

2. Average calorie intake should be 1,400 calories per day.

3. Daily intake of fruits and vegetables should total 2 servings.

4. Healthy diets include a total of 8g protein each day.

2) Average calorie intake should be 1,400 calories per day.

Total fat should be 30% of total caloric intake over several days, not 20% of total daily caloric intake; therefore, the nurse should not include this information in the teaching.

Preschool-age children should consume a total of 5, not 2, servings of fruits and vegetables per day; therefore, the nurse should not include this information in the teaching..

Healthy diets include 13 to 19 g protein each day, not 8 g of total protein each day; therefore, the nurse should not include this information in the teaching.

A nurse is conducting a well-child visit with a 5-year-old child. Which of the following immunizations should the nurse plan to administer to the child? (Select all that apply.)

1. Diphtheria, tetanus, pertussis (DTaP)

2. Inactivated poliovirus (IPV)

3. Measles, mumps, rubella (MMR)

4. Pneumococcal (PCV)

5. Haemophilus influenzae type B (Hib)

1) Diphtheria, tetanus, pertussis (DTaP)

2) Inactivated poliovirus (IPV)

3) Measles, mumps, rubella (MMR)

nurse is performing a developmental screening on a 3-year-old child. Which of the following skills should the nurse expect the child to perform?

1. Bide a tricycle

2. Hop on one foot

3. Jumprope

4. Throw a ball overhead

1) Ride a tricycle

The nurse should expect a 4-year-old child, not a 3-year-old child, to hop on one foot.

The nurse should expect a 5-year-old child, not a 3-year-old child, to be able to jump rope

The nurse should expect a 4-year-old child, not a 3-year-old child, to be able to throw a ball overhead.

 A 3-year-old is hospitalized, and the parent must leave to care for other children but will be back to visit. What observation found in this preschooler would demonstrate the child is experiencing the protest phase of separation anxiety?

A. Loud crying that is inconsolable

B. Withdrawn and sullen

C. Crying quietly and acting out

D. Happy and content 

C. Crying quietly and acting out

Separation anxiety can still present in a preschooler. It usually starts to subside by 4-5 years. During the protest phase the preschooler is different than the toddler in that he or she will be crying quietly and may act out...the toddler will be loudly crying that is inconsolable. The preschooler will generally act the same as the toddler during the despair and detachment phase.

You're assessing the development of a 5-year-old. Which of the following are FINE motor skills a child should be able to perform at this age? Select-all-that-apply:

A. Ride a tricycle 

B. Use blunt tip scissors 

C. Hop

D. Skip

E. Copy triangles and circles 

F. Print their first name 

B. Use blunt tip scissors 

E. Copy triangles and circles 

F. Print their first name 

Fine motor skills are skills that require small muscles for holding and using objects (using scissors, copying shaped and writing etc.).

Your patient is 4-years-old. According to Erikson's Stages of Psychosocial Development the child should develop ____________ by the end of their developmental stage.

A. trust

B. purpose

C. autonomy 

D. competence

B. purpose

Ages 3-5 years include preschoolers, and according to Erikson's Stages of Psychosocial Development the child is in the Initiative vs. Guilt stage. The child is learning how to venture out and be independent. If they are able to do this (not discouraged or restraint) the child will develop a sense of purpose and be able to go to the next stage, which is Industry vs. Inferiority.

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level?

1. Peer pressure

2. Social pressure

3. Parents' behavior

4. Punishment and reward

4) Punishment and reward

Rationale: In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child's actions are good, the child is praised. If the child's actions are bad, the child is punished. Options 1, 2, and 3 are not associated factors for this stage of moral development.

A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? Select all that apply.

1. Set limits on the child's behavior.

2. Ignore the child when this behavior occurs.

3. Allow the behavior, because this is normal at this age period

4. Provide a simple explanation of why the behavior is unacceptable.

5. Punish the child every time the child says "no" to change the behavior.

1) Set limits on the child's behavior.

4) Provide a simple explanation of why the behavior is unacceptable.

Rationale: According to Erikson, the child focuses on gaining some basic control over self and the environment and independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Providing a simple explanation of why certain behaviors are unacceptable is an appropriate action.

Options 2 and 3 do not address the child's behavior. Option 5 is likely to produce a negative response during this normal developmental pattern.

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears?

1. Encourage the child's parents to stay with the child.

2. Encourage play with other children of the same age.

3. Advise the family to visit only during the scheduled visiting hours.

4. Provide a private room, allowing the child to bring favorite toys from home.

1) Encourage the child's parents to stay with the child.

Rationale: Although the preschooler already may be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Options 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question and, in addition, may not be appropriate for a child who may be immunocompromised and at risk for infection.

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child?

1. A radio

2. A sports video

3. Large picture books

4. Crayons and a coloring book

4) Crayons and a coloring book

Rationale: In the preschooler, play is simple and imaginative and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. A radio or a sports video is most appropriate for the adolescent. Large picture books are most appropriate for the infant.

The mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which?

1. A wagon

2. A golf set

3. A farm set

4. A jack set with marbles

1) A wagon

Rationale: Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, large trucks, and dolls are some of the appropriate toys. A farm set, a golf set, and jacks with marbles may contain items that the child could swallow.

A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound.

The home care nurse develops a plan of care that addresses which personality disorder?

1. Avoidant

2. Borderline

3. Schizotypal

4. Obsessive-compulsive

1) Avoidant

Rationale: The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejec-tion. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfec-tionism, the need to control others, and a devotion to work.

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include?

1. Increase socialization of the client with peers.

2. Avoid using a whisper voice in front of the client.

3. Begin to educate the client about social supports in the community.

4. Have the client sign a release of information to appropriate parties for assessment purposes.

2) Avoid using a whisper voice in front of the client.

Rationale: Disturbed thought process related to paranoid personality disorder is the client's problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder.

A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms?

1. Regression

2. Splitting

3. Undoing

4. Identification

2) Splitting

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder?

1. "I'm scared that you're going to leave me."

2. "'I go to group therapy if you'l let me smoke."

3. "I need to feel that everyone admires me."

4. "I sometimes feel better if I cut myself"

1) "I'm scared that you're going to leave me."

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.)

1. Demonstrates extreme anxiety when placed in a social situation

2. Often engages in magical thinking

3. Attempts to convince other clients to relinquish their belongings

4. Becomes agitated if personal area is not neat and orderly compulsive

5. Blames others for personal past and current problems

3) Attempts to convince other clients to relinquish their belongings

5) Blames others for personal past and current problems

A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (Select all that apply.)

1. Difficulty in getting along with other members of a group

2. Belief in the ability to become invisible during times of stress

3. Display of defense mechanisms when routines are changed

4. Claiming to be more important than other persons

5. Difficulty understanding why it is inappropriate to have a personal relationship with staff

1) Difficulty in getting along with other members of a group

3) Display of defense mechanisms when routines are changed

5) Difficulty understanding why it is inappropriate to have a personal relationship with staff

A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse.

Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

1. "I can promote my client's sense of control by establishing a schedule."

2. "I should encourage clients who have a schizoid personality disorder to increase socialization."

3. “I should practice limit-setting to help prevent client manipulation."

4. "I should implement assertiveness training with clients who have antisocial personality disorder."

3) “I should practice limit-setting to help prevent client manipulation."

A nurse is obtaining a nursing history from a client who has a new diagnosis of anorexia nervosa.

Which of the following questions should the nurse include in the assessment? (Select all that apply.

1. “What is your relationship like with your family?"

2. "Why do you want to lose weight?"

3. “Tell me about your current eating habits."

4. "At what weight do you believe you will look better?"

5. "Let's discuss your feelings about your appearance."

1) “What is your relationship like with your family?"

3) “Tell me about your current eating habits."

5) "Let's discuss your feelings about your appearance."

nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and current weight of 90 Ib. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing?

1. "Life isn't worth living if I gain weight."

2. "Don't pretend like you don't know how fat am."

3. "If I could be skinny, I know I'd be popular"

4. "When I look in the mirror, I see myself as obese."

1) "Life isn't worth living if I gain weight."

The other statements reflect the cognitive distortion of personalization, overgeneralization, and a perception of distorted body image.

A nurse is pertorming an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply.)

1. Amenorrhea Anorexice

2. Hypokalemia

3. Yellowing of the skin

4. Slightly elevated body weight

5. Presence of lanugo on the face

2) Hypokalemia

4) Slightly elevated body weight

Other findings associated with Anorexia Nervosa

A nurse is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following actions should the nurse include in the client's plan of care?

1. Allow the client to select preferred meal times.

2. Establish consequences for purging behavior.

3. Provide the client with a high-fat diet at the start of treatment.

4. Implement one-to-one observation during meal times.

4) Implement one-to-one observation during meal times.

Provide a highly structured milieu, including meal times, for the client requiring acute care for the treatment of anorexia nervosa. Use a positive approach to client care that includes rewards rather than consequences. Limit high-fat and gas-producing foods at the start of treatment.

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make?

1. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet."

2. "Instead of worrying about your weight, try to focus on other problems at this time."

3. “I understand you have concerns about your weight, but first, let's talk about your recent accomplishments."

4. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."

3) “I understand you have concerns about your weight, but first, let's talk about your recent accomplishments."

Palliative care is any form of care or treatment that focuses on reducing the severity of disease symptoms to prevent and relieve suffering and improve quality of life for patients with serious life-threatening illnesses. From the subsequent list, identify the specific goals of palliative care (select all that apply).

1. Regard dying as a normal process.

2. Minimize the financial burden on the family.

3. Provide relief from symptoms, including pain.

4. Affirm life and neither hasten nor postpone death.

5. Prolong the patient's life with aggressive new therapies.

6. Support holistic patient care and enhance quality of life.

7. Offer support to patients to live as actively as possible until death.

8. Help the patient and family identify and access pastoral care services.

9. Offer support to the family during the patient's illness and their own bereavement.

1) Regard dying as a normal process.

3) Provide relief from symptoms, including pain.

4) Affirm life and neither hasten nor postpone death.

6) Support holistic patient care and enhance quality of life

7) Offer support to patients to live as actively as possible until death.

8 ) Offer support to the family during the patient's illness and their own bereavement.

A terminally ill patient is unresponsive and has cold, clammy skin with mottling on the extremities. The patient's husband and 2 grown children are arguing at the bedside about where the patient's funeral should be held. What should the nurse do first?

1. Ask the family members to leave the room if they are going to argue.

2. Take the family members aside and explain that the patient may be able to hear them.

3. Tell the family members that this decision is premature because the patient has not yet died

4. Remind the family that this should be the patient's decision and to ask her if she regains consciousness.

2) Take the family members aside and explain that the patient may be able to hear them.

Hearing is often the last sense to disappear with declining consciousness, and conversations can distress patients even when they appear unresponsive.
Conversation around unresponsive patients should never be other than that which one would maintain if the patients were alert.

A patient with end-stage liver failure tells the nurse, "If I can just live to see my first grandchild who is expected in 5 months, then I can die happy." The nurse recognizes that the patient is showing which stage of grieving?

1. Prolonged grief disorder

2. Kübler-Ross's stage of bargaining

3. Kübler-Ross's stage of depression

4. The new normal stage of the Grief Wheel

2) Kübler-Ross's stage of bargaining

Kübler-Ross describes bargaining as being demonstrated by "if-then" grief behavior. Kübler-Ross's stage of depression is seen when the person says, "Yes me, and I am sad." Prolonged grief disorder is seen when there is a dysfunctional reaction to loss, and the individual is unable to move forward after the death of a loved one. In the Grief Wheel model, the new normal stage is when the grief is resolved but the normal state, because of the loss, is different from before.

In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents?

1. Natural death acts

2. Allow natural death

3. Advance care planning

4. Do-not-resuscitate order

1) Natural death acts

Natural death acts are the legal documents in each state that have the state's requirements related to an individual's choice of health care. Allow natural death is a new term being used for the Do Not Resuscitate order.
Advance care planning is the process of having patients and their families think through their values and goals for treatment and document those wishes as advance directives.

A deathly ill patient from a culture different than the nurse's is admitted. Which question is appropriate to help the nurse provide culturally competent care?

1. "If you die, will you want an autopsy?"

2. "Are you interested in learning about palliative or hospice care?"

3. "Do you have any preferences for what happens if you are dying?"

4. "Tell me about your expectations of care during this hospitalization."

4) "Tell me about your expectations of care during this hospitalization."

Using the open-ended statement to seek information related to the patient's and family's perspective and expectations will best guide the plan of care for this patient. This will open the discussion about palliative or hospice care and preferences for end-of-life care.