Following a lumbar puncture, a client voices several
complaints. What complaint indicated to the nurse that
the client is experiencing a
... [Show More] complication?
A. “I have a headache that gets worse when I sit up”
B. “I am having pain in my lower back when I move my
legs”
C. “My throat hurts when I swallow”
D. “I feel sick to my stomach and am going to throw up”
A mother brings her 6-year-old child, who has just stepped
on a rusty nail, to the pediatrician’s office. Upon inspection,
the nurse notes that the nail went through the shoe and
pierced the bottom of the child’s foot. Which action should
the nurse implement first?
E. Cleanse the foot with soap and water and apply an
antibiotic ointment
F. Provide teaching about the need for a tetanus booster
within the next 72 hours.
G. have the mother check the child's temperature q4h
for the next 24 hours
H. transfer the child to the emergency department to
receive a gamma globulin injection
A 26-year-old female client is admitted to the hospital for
treatment of a simple goiter, and levothyroxine sodium
(Synthroid) is prescribed. Which symptoms indicate to the
nurse that the prescribed dosage is too high for this client?
The client experiences
A. Bradycardia and
constipation B. Lethargy
and lack of appetite
C. Muscle cramping and dry,
flushed skin D. Palpitations and
shortness of breath
The pathophysiological mechanism are responsible for ascites
related to liver failure? (Select all that apply
A. Fluid shifts from intravascular to interstitial area due
to decreased serum protein
B. Increased hydrostatic pressure in portal circulation
increases fluid shifts into abdomen
C. Increased circulating aldosterone levels that
increase sodium and water retention
The nurse notes that a client has been receiving
hydromorphone (Dilaudid)
every six hours for four days. What assessment is most
important for the nurse to complete?
A. Auscultate the client's bowel sounds
B. Observe for edema around the ankles
C. Measure the client’s capillary glucose level
D. Count the apical and radial pulses simultaneously
After a third hospitalization 6 months ago, a client is admitted
to the hospital with ascites and malnutrition. The client is
drowsy but responding to verbal stimuli and reports recently
spitting up blood. What assessment finding warrants
immediate intervention by the nurse?
A. Capillary refill of 8 seconds
B. bruises on arms and legs
C. round and tight abdomen
D. pitting edema in lower legs
The client with which type of wound is most likely to need
immediate intervention by the nurse?
A. Laceration
B. Abrasion
C. Contusion
D. Ulceration
When caring for a client who has acute respiratory distress
syndrome (ARDS), the nurse elevates the head of the bed
30 degrees. What is the reason for this intervention?
A. To reduce abdominal pressure on the diaphragm
B. to promote retraction of the intercostal accessory muscle of
respiration
C. to promote bronchodilation and effective airway clearance
D. to decrease pressure on the medullary center which
stimulates breathing
When assessing a mildly obese 35-year-old female client, the
nurse is unable to locate the gallbladder when palpating
below the liver margin at the lateral border of the rectus
abdominal muscle. What is the most likely explanation for
failure to locate the gallbladder by palpation?
A. The client is too obese
B. Palpating in the wrong abdominal quadrant
C. Deeper palpation technique is
needed D. The gallbladder is
normal
A woman with an anxiety disorder calls her obstetrician’s
office and tells the nurse of increased anxiety since the
normal vaginal delivery of her son three weeks ago. Since she
is breastfeeding, she stopped taking her antianxiety
medications, but thinks she may need to start taking them
again because of her increased anxiety. What response is best
for the nurse to provide this woman?
A. describe the transmission of drugs to the infant through
breast milk
B. encourage her to use stress relieving alternatives,
such as deep breathing exercises
C. Inform her that some antianxiety medications are
safe to take while breastfeeding
D. Explain that anxiety is a normal response for the
mother of a 3-week- old
An older male client with a history of type 1 diabetes has not
felt well the past few days and arrives at the clinic with
abdominal cramping and vomiting. He is lethargic,
moderately, confused, and cannot remember when he took
his last dose of insulin or ate last. What action should the
nurse implement first?
A. Start an intravenous (IV) infusion of normal saline
B. obtain a serum potassium level
C. administer the client's usual dose of insulin
D. assess pupillary response to light [Show Less]