A client is admitted with rapid atrial flutter is receiving amiodarone 1mg/min via a
peripheral line. The UAP reports to the nurse that the client's HR
... [Show More] is 90 BPM, and BP is
110/50. Which intervention should the nurse implement?
1. tell the uap to turn off the amiodarone
2. restart the IV infusion in another site
3. Determine the regularity of the peripheral pulses
4. Evaluate the rhythm of the heart rate - ANSWER $. Evaluate the rhythm of the heart
rate
The nurse notes there is bloody drainage trickling from under a client who had a
thyroidectomy yesterday. Which action should the nurse take?
1. Apply pressure to client's incision.
2. reinforced the dressing with sterile gauze
3. Remove the dressing and apply steri strips
4. Assess the client's ability to swallow - ANSWER 4. Assess the client's ability to
swallow
A client tells the nurse that her biopsy results indicate that the cancer cells were well
differentiated. How should the nurse respond?
1. Offer the client reassurance that this indicates the cancer cells are benign
2. explain that these tissue cells often respond more effectively to radiation than chemo
3. help the client make plans to begin immediate treatment since her cancer is likely to
spread
4. Ask the client if the healthcare provider has given her any information about the
classification of her cancer - ANSWER 4.
the nurse is teaching a client recently diagnosed with SLE about self-care. Which
instruction should be included in this client's teaching plan?
1. Encourage use of a cromolyn inhaler prior to activity
2. use tanning beds in place of sun bathing
3, remove tags, curtains, and other dust collection items in the home
4. avoid large crowds and people with infections - ANSWER 4, avoid large crowds and
people with infections
a client is being treated for SIADH. On examination the client has a weight gain of
4.4lbs. In 24 hours, and an elevated HR. Which intervention should the nurse implement
first?
1. Record usual eating patterns
2. Measure ankle circumference
3. Review ABG's
4. Enurse the client takes a diuretic every morning - ANSWER 4. Ensure the client takes
a diuretic every morning
A client recently diagnosed with DM is admitted with watery diarrhea, deep rapid
respirations, and reports having a sever headache for the past week. VS 80/40, HR 134
bpm, RR 36. Which interventions should the nurse implement first
1. Rapidly infused bolus of NS
2. Obtain the clietns admission weight
3. Check the urine for ketones
4. Assess for evidence of fruity breath - ANSWER !. Rapidly infused bolus of NS
A client with DM seems confused and parents with onset of headache, polyuria, fatigue,
and blurry vision. What action should the nurse implement.
1. Arrange for a vision consultation
2. Request a urine culture
3. Provide the client with a cup of juice
4. check the client's blood glucose - ANSWER 4. check the client's blood glucose
After 3 days of nausea, vomiting, and fatigue a client with adrenal insufficiency presents
to the ED. Which findings attained during the admission assessment warrants
immediate intervention by the nurse
1. Postural hypotension
2. extremity weakness
3. Signs of dehydration
4. Increased HR - ANSWER 3. Signs of Dehydration
A client with HF is admitted to the medical surgical unit with pneumonia. To reduce
cardiac workload, which interventions should the nurse include in the plan of care
1. assist with ambulation in the hallway
2. teach to sleep in a side lying position
3. provide a bedside commode for toileting
4. encourage active range of motion exervcises - ANSWER 3. Provide a bedside
commonde for toileting
A client with hyperthyroidism tells the nurse " I stopped taking my anti-thyroid
medication and now I feel anxious. I can feel my heart pounding. Which assessment is
most important for the nurse to obtain
1. VS
2. Peripheral pulses
3. Emotional status
4. Presence of goiter - ANSWER 1. VS
An older client with a history of anemia presents to the clinic with weakness and general
fatigue. Which assessment should the nurse perform to evaluate the client's tissue
perfusion
1. observe for bruising on the arms and legs
2. note the presence of nailbed cyanosis
3. palpate the volume of the pedal pulses
4. determine elasticity of skin turgor - ANSWER B. Note the presence of nail bed
cyanosis
A client is being treated for AKI. On exam the client has generalized edema and
changes in mental status. Which intervention should the nurse include in the client's
plan of care
1. measure the ankle circumference e
2. auscultate for irregular HR
3. Review ABG results
4. Measure and document urine output - ANSWER 4. measure and document urine
output
An older male client is brought to the ED by his daughter. He is complaining of
abdominal pain and the inability to urine, except for small amounts of incontinence, what
action should the nurse implement first?
1. scan bladder to determine amount of urine in bladder
2. insert an indwelling catheter to drain bladder of retained urine
3. obtain a urine sample from incontinnce for culture and sensivity
4. administer IV pain medication for the abd pain - ANSWER 1. scan bladder
The HCP prescribes an IV fluid bolus for a client in adrenal crisis who is confused and
unncooperative. The RN has attempted to obtain IV access twice without success. The
client's VS are temp 103, BP 88/50, HR 132 and RR 30. Which intervention should the
nurse implement first
1. insert a temporary intraosseous access
2. Have a family remain at bedside
3. ask charge nurse to assist with access
4. Ask HCP to obtain central line access - ANSWER 3. Ask charge nurse to assist with
access
an adult male is admitted with dyspnea on exertion, persistent cought, and palpitations.
The telemetry revels a-fib. Which additional findings warrants the most immediate
interventions by the nurse.
1. Production of frothy, pink tinged sputum.
2. Pitting edema of the ankles bilaterally
3. RR of 22 breaths/min
4. Irregular apical heart rhythm - ANSWER 1. Production of frothy pink tinged sputum
A client with AIDS has impaird gas exchange from a respiratory infection. Which
assessment finding warrants immediate intervention by the RN
1. Generalized weakness
2. Pain when swallowing
3. Diminished lung sounds
4. Elevated temperature - ANSWER 2. Pain when swallowing
A client who is having an acute addisonian crisis is tachycardiac and hypotensice.
Which intervention is most important for the RN to include in the client's plan of care
1. maintain protective isolation
2. monitor for signs of shock
3. Protect from noise, light and temperatures
4. Encourage diet supplements with meals - ANSWER monitor for signs of shock
a male client reports feeling chronically fatigued and has a hgb of 11.0, hct of 34% and
microcytic and hypochromic rbc's. Based on this findings, which dinner would the RN
suggest for the client
1. Beef steak with steamed broccoli and orange slice
2. grilled shrimp with rice and asparagus salad
3. broiled white fish and baked sweet potato
4. cheese pasta and a lettuce and tomato salad - ANSWER 1. Beef steak with steamed
broccoli and orange slices
A client with Addison's disease is taking hydrocortisone in divided daily does last week.
It is most important for the nurse to monitor which serum lab value
1. osmolality
2. albumin
3. Platelets s
4. Glucose - ANSWER 4. Glucose
A young adult male is being discharged from the hospital after orchiectomy for testicular
cancer. Which instructions should the nurse provide to him regarding care of the
incision
1. Keep the bandage dry and change it daily
2. wear a scrotal support until sutures are removed
3. leave the incision open to air and wear boxer shorts
4. leave bandage in place until the follow up visit - ANSWER 2. wear a scrotal support [Show Less]