Evolve Med Surg Practice (Exam 475) 123 Questions with Verified Answers
Which description of symptoms is characteristic of a client diagnosed with
... [Show More] trigeminal neuralgia (tic douloureux)? - CORRECT ANSWER B) Sudden, stabbing, severe pain over the lip and chin.
A 67-year-old woman who lives alone is admitted after tripping on a rug in her home and fractures her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur? - CORRECT ANSWER C) Osteoporosis resulting from hormonal changes.
The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first? - CORRECT ANSWER D) Allow the client to sit with the bed in a high Fowler's position.
A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? - CORRECT ANSWER B) Most lumps are benign, but it is always best to come in for an examination.
A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement? - CORRECT ANSWER D) Collect further data to determine whether self-neglect is occurring.
A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result should the nurse expect this client to exhibit? - CORRECT ANSWER C) Elevated CK-MB.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? - CORRECT ANSWER A) Prevention of deformities.
The nurse should be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's - CORRECT ANSWER C) serum potassium level is 3.
Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing painting the house with the client. The nurse suggests that the edge of the steps should be painted which color?
A) Black.
B) White.
C) Light green.
D) Medium yellow. - CORRECT ANSWER D) Medium yellow.
Yellow is the easiest for a person with failing vision to see (D). (A) will be almost impossible to see at night because the shadows of the steps will be too difficult to determine, and would pose a safety hazard. (B) is very hard to see with a glare from the sun and it could hurt the eyes in the daytime to look at them. (C) is a pastel color and is difficult for elderly clients to see.
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? - CORRECT ANSWER B) Reposition the head to validate that the head is in the proper position to open the airway.
The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?
. - CORRECT ANSWER A) Cyanosis of the fingertips.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? - CORRECT ANSWER C) Potassium.
A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client? - CORRECT ANSWER D) Adequate cellular nourishment.
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which treatment protocol? - CORRECT ANSWER C) Anticoagulation therapy.
Which information about mammograms is most important to provide a post-menopausal female client? - CORRECT ANSWER C) Yearly mammograms should be done regardless of previous normal x-rays.
In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer? - CORRECT ANSWER B) A 50-year-old whose mother had unilateral breast cancer.
A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? - CORRECT ANSWER C) Schedule extra rest periods.
Which reaction should the nurse identify in a client who is responding to stimulation of the sympathetic nervous system? - CORRECT ANSWER B) Increased heart rate.
.
A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency? - CORRECT ANSWER A) K.
The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing diagnosis should the nurse document for this client? - CORRECT ANSWER B) Disabled family coping related to dissonant coping style of significant person.
When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? - CORRECT ANSWER A) Place a small book or magazine on the abdomen and make it rise while inhaling deeply.
A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?
. - CORRECT ANSWER A) He visits his diabetic brother who just had surgery to amputate an infected foot.
After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? - CORRECT ANSWER C) 5 minutes before and 30 minutes after the next dose.
During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom should the nurse expect this client to have? - CORRECT ANSWER D) Productive cough with grayish-white sputum.
What discharge instruction is most important for a client after a kidney transplant? - CORRECT ANSWER C) Use daily reminders to take immunosuppressants.
A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client? - CORRECT ANSWER D) Digoxin (Lanoxin).
What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast? - CORRECT ANSWER D) Perform a breast self-exam (BSE) procedure monthly.
After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented? - CORRECT ANSWER A) Report the findings to the surgeon.
The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding should the nurse expect this client to exhibit? - CORRECT ANSWER C) Normal skin coloring.
A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's - CORRECT ANSWER C) temperature.
Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation? - CORRECT ANSWER B) Place a large tourniquet at the client's bedside.
An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client is most likely to reveal which sign/symptom? - CORRECT ANSWER D) Confusion and tachycardia.
The nurse is teaching a client with maple syrup urine disease (MSUD), an autosomal recessive disorder, about the inheritance pattern. Which information should the nurse provide? - CORRECT ANSWER C) Both genes of a pair must be abnormal for the disorder to occur.
The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? - CORRECT ANSWER B) Serum calcium of 5 mg/dl.
A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client? - CORRECT ANSWER D) Feelings of dizziness.
A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? - CORRECT ANSWER B) Calcium loss from bones can be slowed by increasing calcium intake and exercise.
A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? - CORRECT ANSWER C) A potassium supplement will be prescribed.
The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints? - CORRECT ANSWER C) Initiate a weight-reduction diet to achieve a healthy body weight.
When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? - CORRECT ANSWER D) Elimination of hazards to home safety.
A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? - CORRECT ANSWER D) At what time do you take your medication?
The nurse knows that lab values sometimes vary for the older client. Which data should the nurse expect to find when reviewing laboratory values of an 80-year-old male?
. - CORRECT ANSWER C) Increased protein in the urine, slightly increased serum glucose levels.
Which client should the nurse recognize as most likely to experience sleep apnea? - CORRECT ANSWER B) Obese older male client with a short, thick neck.
The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? - CORRECT ANSWER A) She sustained an insect bite to her left arm yesterday.
A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? - CORRECT ANSWER D) The test you are having tomorrow requires that you have nothing by mouth tonight.
The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? - CORRECT ANSWER D) If the client's wound is infected.
The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) - CORRECT ANSWER D) Do not leave the diaphragm in place longer than 8 hours after intercourse.
E) Contact a healthcare provider a sudden onset of fever grater than 101º F appears.
A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? - CORRECT ANSWER B) The immunization is administered once to older adults or persons with a history of chronic illness.
The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms should this client most likely exhibit? - CORRECT ANSWER B) Shuffling gait, masklike facial expression, and tremors of the head.
A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide? - CORRECT ANSWER A) Estrogen deficiency causes the vaginal tissues to become dry and thinner.
An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns? - CORRECT ANSWER A) Regenerative function of the skin is absent because the dermal layer has been destroyed.
Which symptoms should the nurse expect a client to exhibit who is known to have a pheochromocytoma? - CORRECT ANSWER B) Headache, diaphoresis, and palpitations.
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) - CORRECT ANSWER A) Set the infusion pump to infuse the albumin within four hours.
D) Administer through a large gauge catheter.
E) Monitor hemoglobin and hematocrit levels.
F) Assess for increased bleeding after administration.
(A, D, E, and F) are the correct selections.
Physical examination of a comatose client reveals decorticate posturing. Which statement is accurate regarding this client's status based upon this finding? - CORRECT ANSWER B) Severe dysfunction of the cerebral cortex has occurred.
The nurse formulates the nursing diagnosis of, Urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement? - CORRECT ANSWER A) Teach the client techniques of intermittent self-catheterization.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? - CORRECT ANSWER A) Lower left quadrant pain and a low-grade fever.
A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority? - CORRECT ANSWER D) Check the client's gag and swallow reflexes.
A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide? - CORRECT ANSWER D) AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual.
A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response? - CORRECT ANSWER B) Discuss perimenopause and related comfort measures.
The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? - CORRECT ANSWER C) Willingness of the client to learn the injection sites.
An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain should further confirm this suspicion? - CORRECT ANSWER C) Pain in the calf upon exertion which is relieved by rest and elevating the extremity.
The nurse is planning care for a client who has a right hemispheric stroke. Which nursing diagnosis should the nurse include in the plan of care? - CORRECT ANSWER B) Risk for injury related to denial of deficits and impulsiveness.
A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? - CORRECT ANSWER C) The tumor's estrogen receptor guides treatment options.
Which healthcare practice is most important for the nurse to teach a postmenopausal client? - CORRECT ANSWER C) Consume adequate foods rich in calcium.
A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? - CORRECT ANSWER A) Start an IV nitroglycerin infusion.
While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test? - CORRECT ANSWER C) Four to six weeks after the exposure.
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include?
. - CORRECT ANSWER B) Increase intake of soluble fiber to 10 to 25 grams per day.
When preparing a client who has had a total laryngectomy for discharge, which instruction is most important for the nurse to include in the discharge teaching?
A) Recommend that the client carry suction equipment at all times.
B) Instruct the client to have writing materials with him at all times.
C) Tell the client to carry a medic alert card stating that he is a total neck breather.
D) Tell the client not to travel alone. - CORRECT ANSWER C) Tell the client to carry a medic alert card stating that he is a total neck breather.
It is imperative that total neck breathers carry a medic alert notice (C) so that if they have a cardiac arrest, mouth-to-neck breathing can be done. Mouth-to-mouth resuscitation will not help them. They do not need to carry (A) nor refrain from (D). There are many alternative means of communication for clients who have had a laryngectomy; depending on (B) is probably the least effective. How do you know he can read and write?
A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider? - CORRECT ANSWER A) Lung tissue biopsy.
A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration? - CORRECT ANSWER A) Serum creatinine.
Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client? - CORRECT ANSWER D) Advise the client to remain in bed with the leg elevated.
The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia? - CORRECT ANSWER A) Sweating, trembling, tachycardia.
What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina? - CORRECT ANSWER D) For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye.
A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement? - CORRECT ANSWER D) Give an antihypertensive medications.
A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because - CORRECT ANSWER B) gram-negative organisms are more resistant to antibiotic therapy.
The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide? - CORRECT ANSWER A) Two weeks before menstruation.
During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? - CORRECT ANSWER B) Attempt to reinsert the tracheostomy tube.
A male client who has never smoked but has had COPD for the past 5 years is now being assessed for cancer of the lung. The nurse knows that he is most likely to develop which type of lung cancer? - CORRECT ANSWER A) Adenocarcinoma.
The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding should the nurse consider an indication of progressive hepatic encephalopathy? - CORRECT ANSWER D) Difficulty in handwriting.
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? - CORRECT ANSWER B) Initiate continuous cardiac monitoring.
A client is brought to the Emergency Center after a snow-skiing accident. Which intervention is most important for the nurse to implement? - CORRECT ANSWER A) Review the electrocardiogram tracing.
The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include? - CORRECT ANSWER C) Maintain a fluid intake of 3 to 4 L per day.
The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement? - CORRECT ANSWER B) Call for an ECG to be performed immediately.
A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? - CORRECT ANSWER D) Inflammatory with peau d'orange.
A client is placed on a respirator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12h IV is prescribed. Which nursing diagnosis is the priority for this client? - CORRECT ANSWER A) Impaired communication related to paralysis of skeletal muscles.
Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation? - CORRECT ANSWER B) Wear gloves when coming in contact with the blood or body fluids of any client.
A client who is sexually active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide?
. - CORRECT ANSWER A) Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID).
The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information is most useful to the nurse when planning activities for the group?
. - CORRECT ANSWER D) The usual activity patterns of each member of the group.
Which milestone indicates to the nurse successful achievement of young adulthood? - CORRECT ANSWER B) Completes education and becomes self-supporting.
Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? - CORRECT ANSWER C) 3+ bacteria in urine.
A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? - CORRECT ANSWER D) Raising the head of the bed on blocks.
The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic renal failure who is complaining of indigestion. What intervention should the nurse implement? - CORRECT ANSWER D) Question the healthcare provider's prescription.
A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement? - CORRECT ANSWER C) Provide back and skin care while maintaining the traction.
A client reports unprotected sexual intercourse one week ago and is worried about HIV exposure. An initial HIV antibody screen (ELISA) is obtained. The nurse teaches the client that seroconversion to HIV positive relies on antibody production by B lymphocytes after exposure to the virus. When should the nurse recommend the client return for repeat blood testing? - CORRECT ANSWER D) 6 to 12 weeks.
The nurse is assessing a client with chronic renal failure (CRF). Which finding is most important for the nurse to respond to first? - CORRECT ANSWER A) Potassium 6.0 mEq.
A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? - CORRECT ANSWER B) Inability to get pregnant.
During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide? - CORRECT ANSWER C) Insurance coverage of employees is less expensive to employers.
How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? - CORRECT ANSWER D) Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line.
During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client? - CORRECT ANSWER A) Muscle weakness.
The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question should provide information relevant to the client's plan of care? - CORRECT ANSWER C) Have you ever been 'frozen' in one spot, unable to move?
A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain?
. - CORRECT ANSWER B) An accurate menstrual cycle diary for the past 6 to 12 months.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested by which symptoms? - CORRECT ANSWER A) Loss of thirst, weight gain.
What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode? - CORRECT ANSWER D) Bronchodilators and steroids.
A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. What content is most important for the nurse to include in the discharge teaching for this client? - CORRECT ANSWER A) Information about smoking cessation.
Which postmenopausal client's complaint should the nurse refer to the healthcare provider? - CORRECT ANSWER C) Episodes of vaginal bleeding.
Dysrhythmias are a concern for any client. However, the presence of a dysrhythmia is more serious in an elderly person because - CORRECT ANSWER D) elderly persons are intolerant of decreased cardiac output which may result in dizziness and falls.
A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or her family on admission? "Does the client - CORRECT ANSWER D) take digitalis?"
The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? - CORRECT ANSWER B) Check for tube placement and residual volume q4 hours.
A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement? - CORRECT ANSWER C) Advise the client to notify the healthcare provider for immediate medical attention.
A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? - CORRECT ANSWER C) Purulent sputum.
Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder? - CORRECT ANSWER B) Encourage the client to perform Kegel exercises 10 times daily.
Which assessment finding by the nurse during a client's clinical breast examination requires follow-up? - CORRECT ANSWER A) Newly retracted nipple.
A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? - CORRECT ANSWER B) Evaluate his blood pressure, pulse, and respiratory status.
The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement? - CORRECT ANSWER B) Shock the client with 200 joules per hospital policy.
The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note? - CORRECT ANSWER B) An allergy to sulfa drugs.
Small bowel obstruction is a condition characterized by which finding? - CORRECT ANSWER A) Severe fluid and electrolyte imbalances.
A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? - CORRECT ANSWER A) Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant.
In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important? - CORRECT ANSWER D) Smoking cessation program.
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated? - CORRECT ANSWER A) Help the client to determine ways to increase his fluid intake.
A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? - CORRECT ANSWER A) Propanolol (Inderal).
A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client? - CORRECT ANSWER D) Restrict salt and fluid intake.
The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? - CORRECT ANSWER A) Diabetes mellitus.
A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? - CORRECT ANSWER B) Nocturia
During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? - CORRECT ANSWER C) May indicate pneumonia. [Show Less]