1. A nurse is assessing a client who is 12 he postoperative following a colon
resection. Which of the following findings should the nurse report to the
... [Show More] surgeon?
A. Heart rate 90/min
B. Absent bowel sounds
C. Hgb 8.2 g/dl
D. Gastric pH of 3.0
Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible
hemorrhaging.
2. A nurse is caring who has diabetes insipidus. Which of the following medications
should the nurse plan to administer?
A. Desmopressin
B. Regular insulin
C. Furosemide
D. Lithium Carbonate
Rationale: Diabetes insipidus has decreased ADH. Administer
Desmopressin/Vasopressin increase ADH and to stop patient on urinating.
3. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen
several times daily for 3 years. Which of the following test should the nurse
monitor?
A. Fasting blood glucose
B. Stool for occult blood - GI bleed
C. Urine for white blood cells
D. Serum calcium
4. A nurse is planning care for a client who has Cushing's syndrome due to chronic
corticosteroid use. Which of the following actions should the nurse involve in the
plan of care?
A. Contact the physician
B. Administer antidote
C. Check the client's urine specific gravity.
D. Obtain a sputum culture
Rationale: to assess for fluid volume overload.
5. A nurse is collecting data from a client who has alcohol use disorder and is
experiencing metabolic acidosis. Which of the following manifestations should
the nurse expect?
A. Cool, clammy skin
B. Hyperventilation
C. Increased blood pressure
D. Bradycardia6. A nurse notes a small section of bowel protruding from the abdominal incision of
a client who is postoperative. After calling for assistance, which of the following
actions should the nurse take first?
A. Cover the clients wound with a moist, sterile dressing
B. Have the client lie supine with knees flexed
C. Check the clients vital signs
D. Inform the client about the need to return to surgery
7. A nurse is reinforcing discharge teaching with a client following a cataract
extraction. Which of the following should the nurse include in the teaching?
A. Avoid bending at the waist
B. Remove the eye shield at bedtime
C. Limit the use of laxatives if constipated
D. Seeing flashes of light is an expected finding following extraction
8. A nurse is caring for a client who is 3 days postoperative following a
cholecystectomy. The nurse suspects the clients wound is infected because the
drainage from the dressing is yellow and thick. Which of the following findings
should the nurse report as the type of drainage found?
A. Sanguineous
B. Serous
C. Serosanguineous
D. Purulent
9. A nurse is caring for a client who is postoperative following a tracheostomy, and
has copious and tenacious secretions. Which of the following is an acceptable
method for the nurse to use to thin the clients secretions?
A. Provide humidified oxygen
B. Perform chest physiotherapy prior to suctioning
C. Prelubricate the suction catheter tip with sterile saline when suctioning the
airway.
D. Hyperventilate the client with 100% oxygen before suctioning the airway
10.A nurse is caring for a client who is 4 hours postoperative following a
transuretheral resection of the prostate (TURP). Which of the following is the
priority finding for the nurse to report to the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5 C (99.5 F)
C. Thick red colored urine
D. Pain level of 4 on a 0 to 10 rating scale
11.A nurse is caring for a client who has a temperature of 39.7 and has a
prescription for a hypothermia blanket. The nurse should monitor the client for
which of the following adverse effects of the hypothermia blanket?
A. Shivering
B. InfectionC. Burns
D. Hypervolemia
12.A nurse is caring for a client who has heart failure and has been taking digoxin
0.25 mg daily. The client refuses breakfast and reports nausea. Which of the
following actions should the nurse take first?
A. Suggest that the client rests before eating the meal
B. Request a dietary consult
C. Check the clients vital signs
D. Request an order for an antiemetic
13.A nurse is reinforcing teaching about exercise with a client who has Type 1
diabetes mellitus. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will carry a complex carbohydrate snack with me when I exercise"
B. "I should exercise first thing in the morning before eating breakfast"
C. "I should avoid injecting insulin into my thigh if I am going to go running"
D. "I will not exercise if my urine is positive for ketones"
14.Following admission, a client with a vascular occlusion of the right lower
extremity calls The nurse and reports difficulty sleeping because of cold feet.
Which of the following nursing action should the nurse take to promote the clients
comfort?
A. Rub the clients feet briskly for several minutes
B. Obtain a pair of slipper socks for the client
C. Increase the clients oral fluid intake
D. Place a moist heating pad under the client feet
15.A nurse is reinforcing discharge teaching to a client following arthroscopic
surgery. To prevent postoperative complications which of the following actions
should be reinforced during the teaching?
A. Administer an opioid analgesic to the client 30 minutes prior to
initiating CPM exercises
B. Place the clients affected leg into the CPM machine with the machine in
the flexed position
C. Place the client into a high fowlers position when initiating the CPM
exercises
16.The nurse is assisting with the care of a client who has a femur fracture and is in
skeletal traction. Which of the following actions should the nurse take?
A. Loosen the knots on the ropes if the client is experiencing pain
B. Ensure the clients weights are hanging freely from the bed
C. Check the clients bony prominences every 12 hours
D. Cleanse the clients pin sites with providence-iodine17.A nurse is reinforcing teaching with a client who is postoperative after having an
ileostomy established. Which of the following instructions should the nurse
include in the teaching?
A. Empty the pouch immediately after meals
B. Change the entire appliance once a day
C. Limit fluid intake
D. Avoid medications in capsule or enteric form
18.A nurse is reinforcing teaching with a client who has HIV and is being discharged
to home. Which of the following instructions should the nurse include in the
teaching?
A. Take temperature once a day
B. Wash the armpits and genitals with a gentle cleaner daily
C. Change the litter boxes while wearing gloves
D. Wash dishes in warm water [Show Less]