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
... [Show More] nurse?
The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?
A) Cyanosis of the fingertips.
B) Bradycardia and bradypnea.
C) Presence of S3 and S4 heart sounds.
D) 3+ pitting edema of the lower extremities.
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?
A) Glomerular Filtration Rate (GFR)
B) Blood Urea Nitrogen (BUN).
C) Sedimentation rate.
D) Urine specific gravity.
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?
A) Propanolol (Inderal).
B) Captopril (Capoten).
C) Furosemide (Lasix).
D) Dobutamine (Dobutrex).
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?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength.
0.04 mg/kg q12h IV is prescribed. Which nursing diagnosis is the priority for this client?
A) Impaired communication related to paralysis of skeletal muscles.
B) High risk for infection related to increased intracranial pressure.
C) Potential for injury related to impaired lung expansion.
D) Social isolation related to inability to communicate.
A client is placed on a respirator following a cerebral hemorrhage, and vecuronium bromide (Norcuron)
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
A) have her own teeth or dentures?"
B) take aspirin and if so, how much?"
C) take nitroglycerin?"
D) take digitalis?"
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?
A) Prepare the client for transcutaneous pacemaker.
B) Shock the client with 200 joules per hospital policy.
C) Use a magnet to deactivate the implanted pacemaker.
D) Observe the monitor until the onset of ventricular fibrillation.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?
A) Sodium.
B) Antidiuretic hormone.
C) Potassium.
D) Glucose.
During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client?
A) Muscle weakness.
B) Urinary frequency.
C) Abnormal involuntary movements.
D) A decline in cognitive function.
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?
A) Apply sequential compression devices (SCDs) bilaterally.
B) Assess for a positive Homan's sign in each leg.
C) Pad all bony prominences on the affected leg.
D) Advise the client to remain in bed with the leg elevated.
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which treatment protocol?
A) Diuretic therapy.
B) Pacemaker implantation.
C) Anticoagulation therapy.
D) Cardiac catheterization.
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.
Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia?
The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus.
A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain?
A) Amount of weight gain or weight loss during the previous year.
B) An accurate menstrual cycle diary for the past 6 to 12 months.
C) Skin pigmentation and hair texture for evidence of hormonal changes.
D) Previous birth-control methods and beliefs about the calendar method.
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?
A) Use a laryngoscope to check for a foreign body lodged in the esophagus.
B) Reposition the head to validate that the head is in the proper position to open the airway.
C) Turn the client to the side and administer three back blows.
D) Perform a finger sweep of the mouth to remove any vomitus.
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?
A) A decreased total lung capacity.
B) Normal arterial blood gases.
Which milestone indicates to the nurse successful achievement of young adulthood?
A) Demonstrates a conceptualization of death and dying.
B) Completes education and becomes self-supporting.
C) Creates a new definition of self and roles with others.
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?
A) Losing weight.
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?
A) The length of time each group member has resided at the nursing home.
B) A brief description of each resident's family life.
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?
A) Lower left quadrant pain and a low-grade fever.
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.
"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?
A) This is a normal auscultatory finding.
During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say
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?
A) Long-term relationships with healthcare providers are more likely.
B) There are fewer healthcare providers to choose from than in an HMO plan.
The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include?
A) Safety precautions during activity.
B) Assess for changes in size of lymph nodes.
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?
A) Present knowledge related to the skill of injection.
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?
A) Check it again in one month, and if it is still there schedule an appointment.
B) Most lumps are benign, but it is always best to come in for an examination.
A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?
A) Position the head of the bed (HOB) flat.
B) Withhold intravenous fluids.
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?
A) She sustained an insect bite to her left arm yesterday. [Show Less]