1. A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate
intervention by the nurse?
a. Serum sodium of 185
... [Show More] mEq/L (185 mmol/L)
b. Dry skin with inelastic turgor
c. Apical rate of 100 beats per minute
d. Polyuria and excessive thirst
2. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which
subjective data reported by the client supports the medical diagnosis?
a. Frequent use of chewable and liquid antacids for indigestion
b. SSevereabdominal cramps and diarrhea after eating spicy foods
c. Upper mid-abdominal pain described as gnawing and burning
d. Marked loss of weight and appetite over the last 3-4 months
3. Then nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client’s
eyeballs are protuberant, causing a wide-eyes appearance and eye discomfort. Based on this finding, which
action should the nurse include in this client’s plan of care?
a. Assess for signs of increased intracranial pressure
b. Prepare to administer intravenous levothyroxine
c. Review the client’s serum electrolyte values
d. Obtain a prescription for artificial tear drops
4. To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS),
which interventions should the nurse implement? (Select all that apply)
a. Perform chest physiotherapy
b. Teach the client breathing exercises
c. Initiate passive range of motion exercises
d. Establish a regular bladder routine
e. Encourage use of incentive spirometer
5. A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve
ventilation and reduce venous return?
a. Perform passive range of motion exercises
b. Place the client in high fowler position
c. Administer oxygen per nasal cannula
d. Increase the client’s activity level
6. A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is
immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF).
The nurse determines that the client’s distal pulses are diminished in the left foot. Which interventions
should the nurse implement? (Select all that apply)
A. Verify pedal pulses using a doppler pulse device
B. Evaluate the application of the a splint to the left leg
C. Offer ice chips and oral clear liquids
D. Monitor left leg for pain, pallor, parathesia, paralysis, pressure
E. Administer oral antispasmodics and narcotic analgesics
7. The healthcare provider prescribes diagnostic test for a client whose chest X-ray indicates pneumonia.
Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the
pneumonia?
a. Sputum culture and sensitivity
b. Blood cultures
c. Arterial blood gases (ABG)
d. Computerized tomography (CT) of chest
8. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive
cough, and thickened, tenacious mucous, and the inability to walk up a flight of stairs without experiencing
breathlessness. Which action is most important for the nurse to instruct the client about self-care?
a. Call the clinic if undesirable side effects of medications occur
b. Avoid crowed enclosed areas to reduce pathogen exposure
c. Increase the daily intake of oral fluids to liquefy secretions
d. Teach anxiety reduction methods of feelings of suffocation
9. The home health nurse provides teaching about insulin self-injection to a client who was recently diagnosed
with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into
the abdomen as seen in the video, which instruction should the nurse provide?
a. Select a different injection site
b. Continue with the insulin injection
c. Keep the skin flat rather than bunched
d. Lie down flat for better skin exposure
10. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous
bladder irrigation following a trans-urethral resection of the prostate (TURP). Which is the best initial
nursing action?
a. Provide additional oral fluid intake
b. Measure the client’s intake and output
c. Increase the flow of the bladder irrigation
d. Administer a PRN dose of an antispasmodic agent [Show Less]