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- A client is admitted to the hospital with a diagnosis of pericarditis. The nurse assesses the client for which
- Anterior chest pain
- Pericardial friction rub
- Weakness and irritability
- Chest pain that worsens on inspiration
- The nurse assist a primary health care provider in performing a liver biopsy. After the biopsy, the nurse plans to place
- Prone
- Supine
- A left side-lying position with a small pillow or folded towel under the puncture site.
- A right side-lying position with a small pillow or folded towel under the puncture site.
manifestations that differentiates pericarditis from other cardiopulmonary problems?
the client in which position?
- The nurse is providing dietary instructions to a client who is immobile and experiencing frequent episodes of
- Pasta
- Cabbage
- White bread
- Whole – grain bread
constipation. The client complains that the constipation is uncomfortable. The nurse should tell the client that which food item would be most helpful to include in the diet?
- The nurse is the first responder to the site of a disaster in which several people were injured in a train crash. Which
- A victim with a fractured arm
- A victim with multiple bruises on the legs
- A victim with a severe head injury who is not breathing
- A victim with an upper leg injury who is bleeding profusely
victim of the crash should the nurse attend to first?
- The nurse provides instructions to a female client regarding the procedure for collecting a midstream urine sample.
- Douche before collecting the specimen.
- Cleanse the perineum from front to back.
- Collect the urine in the cup as soon as the urine flow begins.
- Collect the specimen before bedtime, and bring it to the laboratory the next morning.
The nurse should tell the client to perform which action?
- The nurse provides dietary instructions to a client diagnosed with iron-deficiency anemia. The nurse should tell the
- Plums
- Red apples
- Egg whites
- Kidney beans
client to increase the intake of which food item?
- A clear liquid diet has been prescribed for a client. The nurse should offer which item to the client?
- Apple juice
- Orange juice
- Tomato juice
- Ice cream without nuts
- Oxygen by nasal cannula at 4lpm is prescribed for a hospitalized client. The nurse should perform which actions in the
care of the client? Select All That Apply.
- Humidify the oxygen.
- Apply water-soluble lubricant to the nares.
- Instruct the client to breathe through the nose only.
- Instruct the client and family about the purpose of the oxygen.
- Increase the oxygen flow if the client complains dryness in the nares.
- The nurse is caring for a client who is diagnosed with a terminal disease. The nurse should plan which appropriate
- Offer to contact the clergy to support the client’s spiritual needs.
- Make referrals to other disciplines based on the client’s stated needs.
- Plan to balance the client’s need for assistance with that for independence
- Provide extremely thorough answers to each question asked by the client or family.
- Ask the client about goals for the treatment plan and how she or he can best be assisted in achieving these goals.
interventions in the care of the client? Select all that apply.
- The nurse receives a telephone call from the hospital admission office and it is told that a client with human
- Droplet precautions
- Contact precautions
- Standard precautions
- Airborne precautions
immunodeficiency virus (HIV) will be admitted to the nursing unit. In planning infection control measures for the client, which is the best type of isolation precaution that the nurse should prepare?
- The nurse caring for a client after a bowel resection notes that the client is restless notes that the client is restless.
- Check the client’s oxygen saturation level.
- Recheck the vital signs to verify the findings.
- Raise the client’s legs above the level of the heart.
- Slow the rate of the intravenous (IV) fluid infusing.
The nurse takes the client’s vital signs and notes that the pulse rate has increased and that the blood pressure has dropped significantly since the previous readings. The nurse suspects that the client is going into shock and should take which immediate action?
- The nurse is performing an assessment on the client with a diagnosis of a brain tumor that is located in the
- Opisthotonos
- Flaccid quadriplegia
- Decorticate posturing
- Decerebrate posturing
brainstem and notes that the client is assuming the posture in the figure. The nurse contacts that the primary health care provider and reports that the client is exhibiting which assessment finding? Refer to the figure.
- A client newly diagnosed with type 1 diabetes mellitus is taking an intermediate-acting insulin at 0700 daily. The
- Increased appetite and abdominal pain
- Hunger, shakiness and cool clammy skin
- Thirst, red, dry skin, and fruity breath odor
- Increased urination and rapid deep breathing
nurse should monitor the client closely for which signs and symptoms in the late afternoon?
- The nurse is conducting a training session on cardiopulmonary resuscitation (CPR). The nurse should incorporate
- Stop CPR once fatigue is felt.
- Look, listen, and feel for breathing.
- Give compression first, then address airway and breathing.
- Determine cardiac arrest based on unresponsiveness only.
which guideline session?
- A client with a family history of cervical cancer has made an appointment to have a Papanicolaou test done. The
- “Sexual intercourse should be avoided for 24 hours before the test.”
- “If you are menstruating, douching will be required right before the test.”
- “A vaginal hygiene spray should be used for 2 consecutive days before the schedule test.”
- “The test is very uncomfortable, but a local anesthetic will be injected into the vaginal area.
nurse who schedules the appointment should make which statement to the client?
- The nurse has provided instructions to a client scheduled for an exercise electrocardiogram (ECG) (stress test) at
0900 on the following day. The nurse determines that the client needs additional instructions if the client makes which statement?
- “I should not go to gym to work out today.”
- “I should wear sneakers when I come for the test.”
- “I will wear light, loose, comfortable clothing for the procedure.”
- “I cannot eat for 24 hours before the procedure; I should only drink water.”
- A client has undergone cardiac catheterization using the right femoral artery for access. The nurse determines that
the client is experiencing complication of the procedure if which finding is noted?
- Urine output 40ml/hr
- Blood pressure 118/76mmHg
- Pallor and coolness of the right leg
- Respirations 18 breaths per minute
- The nurse in the emergency department is performing an assessment on a client who sustained a right finger
laceration from a fish hook while fishing. The nurse should ask the client which priority question?
- “When was your last physical examination?’
- “Have you had chest x-ray in the last year?”
- “When did you receive your last tetanus immunization?”
- Have you ever sustained this type of injury in the past?”
- A client has been admitted to the hospital with a fractured pelvis sustained in a motor vehicle crash. The nurse
monitors for complications and should assess the client closely for which finding in the early post trauma period?
- Pain
- Fever
- Hematuria
- Bradycardia
- A client has just had a plaster cast removed from the right arm. The nurse assess the skin to ensure intactness and
the should perform which action?
- Soak the arm in warm water for 1 hour.
- Wash the skin gently and apply skin lotion.
- Scrub the skin vigorously with soap and water.
- Instruct the client that continuous skin soaking will be necessary for the next 24 hours.
- The home care nurse is assessing a client who began using peritoneal dialysis 1 week ago. The nurse should suspect
the onset of peritonitis of which finding is noted on assessment?
- Anorexia
- Cloudy dialysate output
- Mild abdominal discomfort
- Oral temperature of 99.0F (37C)
- After cataract surgery on the right eye, a client is taught to avoid strain on the operative eye. Which statement by
the client indicates a need for further teaching?
- I should not rub my eye.
- I can lie on my right side to sleep at night.
- I need to take stool softeners to prevent straining.
- I should avoid bending over lower than my waist level.
- A stapedectomy is performed on a client with otosclerosis. The nurse prepares the client for discharge and should
provide the client with which home care instruction?
- Expect acute vertigo to occur.
- Delay plans for air travel for at least 1 month.
- Lie on the operative ear with the head of the bed flat.
- You can sneeze or blow your nose as you usually do.
- A client with chronic kidney disease returns to the nursing unit after receiving a second hemodialysis treatment; the
nurse is monitoring the client closely for signs of disequilibrium syndrome. What is the sign of this syndrome?
- Irritability
- Tachycardia
- Hypothermia
- Mental confusion
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