Adult Health II Review

A client recovering from coronary artery bypass grafting (CABG) surgery is refusing to cough, reporting pain. What statement by the client would indicate that the nurse's teaching was effective? A. I can use a pillow against my chest to decrease the pain B. If my incision hurts, I should stop coughing immediately C. I don't need to use the incentive spirometer as long as I cough D. I need to cough at least once every four hours

A

A client with a suspected ST-elevation myocardial infarction (STEMI) asks the nurse why they are having chest pain. Which statement by the nurse would be incorrect? A. This happens when you don't take care of yourself B. What makes your chest pain start? C. How long has this been happening? D. Does anything make it worse?

A

A nurse has received change-of-shift report about the following clients on the progressive care unit. Which client should the nurse see first? A. A client with atrial fibrillation experiencing dizziness and needs to use the restroom B. A client with premature atrial contractions, rate 60, who reports palpitations C. A client who is in a sinus rhythm who had an elective cardioversion 2 hours ago D. A client whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone due

A

A nurse is teaching a client who had an acute myocardial infarction (MI) about the reason blood was drawn for cardiac enzyme testing. Which statement by the nurse about the function of cardiac enzyme testing is best? A. It helps to determine the degree of damage to heart tissues B. It will identify the location of the MI C. It will help to determine how well the heart valves are working D. IT will assist in diagnosing the presence of pulmonary congestion

A

A nurse receives change-of-shift report. Which client should the nurse assess first? A. A client who was admitted for chest pain and is reporting new onset indigestion B. A client admitted with cardiomyopathy with report of dyspnea on exertion C. A client admitted with a STEMI 2 days ago and whose CK-MB remains elevated D. A client who was admitted for chest pain and whose telemetry shows occasional premature ventricular contractions (PVCs)

A

The nurse cares for a client after experiencing a myocardial infarction. The client asks why their blood glucose levels are elevated. How should the nurse respond? A. It can be normal for your blood glucose to be elevated after having a heart attack B. You will be diabetic now C. You don't need to be concerned about your blood sugar D. You will need to monitor your blood sugars from now on

A

The nurse cares for a client diagnosed with diverticulosis. What statement by the client should be most concerning for the nurse? A. I really need to limit how much activity I am doing B. I need to eat green, leafy vegetables C. I should increase the amount of fiber I eat D. I need to watch my stools for blood

A

The nurse cares for a client experiencing "coffee ground" emesis for the past 3 days. Which test should the nurse prepare the client for? A. EGD B. Colonscopy C. ERCP D. Barium swallow study

A

The nurse cares for a client who had a craniotomy. What action by the nurse should be of concern? A. Repositions the client every 15 minutes B. Documents intracranial pressure every hour C. Assess the dressing on the head for signs of drainage D. Ensures head of bed is at 30 degrees

A

The nurse cares for a client with cholelithiasis. Which assessment should be most concerning for the nurse? A. Yellow skin color B. Pain right after fatty meals C. Right upper quadrant pain D. Nausea and vomiting

A

The nurse cares for a client with rapid atrial fibrillation and dizziness. What procedure should the nurse prepare the client for? A. Cardiac ablation B. Transeophageal echocardiogram (TEE) C. Percutaneous coronary intervention D. Valve replacement surgery

A

The nurse is admitting a client who has chest pain. Which assessment data suggests that the pain is caused by an acute myocardial infarction (AMI)? A. The pain has lasted longer than 30 minutes B. The pain increases with deep breathing C. The pain is relieved after the client takes nitroglycerin D. The pain is reproducible when the client raises the arms

A

The nurse is assessing a client with PUD. Which finding should the nurse anticipate? A. Daily use of NSAIDS medications B. Constant pain for several months C. Bright red blood in the stool D. Left flank pain along mid-axillary line

A

The nurse is caring for a client diagnosed with Alzheimer's Disease. What statement by the client's significant other should be most concerning to the nurse? A. Sometimes I find them out in the front yard wandering around B. At times, they forget where they left their keys C. Sometimes they don't remember what happened yesterday D. At times, they forget who the new neighbor is

A

The nurse is caring for a client diagnosed with a right sided brain stroke. What should the nurse include in their plan of care? A. Bed alarm attached to the patient B. Picture board for communication C. Allowing time for completing activities D. Assessing mood and affect

A

The nurse is caring for a client diagnosed with cardiomyopathy. What should be included in the client's education? A. Follow strict fluid restriction B. Discontinue drug therapy when symptoms have resolved C. Participate in a vigorous isometric exercise class D. Need to weigh monthly

A

The nurse is caring for a client diagnosed with constipation. Which statement by the client would indicate the need for further teaching? A. I will use a laxative daily to ensure regularity B. I will establish a regular time for having a bowel movement C. I will eat more raw vegetables and fruit D. I will be sure to drink plenty of fluids

A

The nurse is caring for a client diagnosed with dysphagia. What is the priority action for this client prior to eating for the first time? A. Check gag reflex B. Monitor for pocketing of food C. Observe for coughing during meals D. Lower the head of the bed while eating

A

The nurse is caring for a client diagnosed with multiple sclerosis. Which statement by the client would indicate understanding of the disease? A. I may experience times of weakness that can come and go B. I can take medication to cure the disease C. I should increase my exercise routine to include weightlifting and vigorous aerobic exercises D. When my muscles weaken, I will likely not wake again

A

The nurse is caring for a client on a cardiac unit. Telemetry calls the nurse stating that the client is demonstrating asystole on the monitor. What should the nurse's first action be? A. Assess the patient B. Begin CPR C. Call a code blue D. Give intravenous lidocaine

A

The nurse is caring for a client who was diagnosed with ST-segment elevation myocardial infarction (STEMI) yesterday and is now recovering following percutaneous coronary intervention with stent placement. What should be the priority to report to the provider? A. Client reports chest pain B. Surface bleeding at peripheral IV site C. Troponin level continues to be elevated D. The client reports discomfort at the insertion site

A

The nurse is caring for a client with a C3 spinal cord injury. What assessment finding should be most concerning to the nurse? A. Respiratory rate 6 breaths per minute B. Unable to feel sensation below the neck C. Blood pressure 100/70 mmHg D. Unable to move extremities

A

The nurse is caring for a client with a stroke. Which task should the nurse delegate to the unlicensed assistive personnel that is working with the nurse? A. Feeding the client after they passed their swallow study B. Assessing the client's gag reflex C. Teaching the client about how to use a communication board D. Evaluating how much of their meal the client ate

A

The nurse is caring for a client with acute gastrointestinal bleed. Which assessment finding should the nurse find most concerning? A. Urine output 15 ml/hr B. BP 108/52 C. Melena D. Hematemesis

A

The nurse is caring for a client with an ostomy. Which task would not be appropriate to delegate the UAP they are working with? A. Choose appropriate ostomy pouching system B. Place the ostomy pouching system for an established ostomy C. Empty ostomy bag and measure liquid contents D. Open the ostomy pouching system and allow the air out

A

The nurse is caring for a client with early Alzheimer's disease. Which finding should be most concerning to the nurse? A. Forgets to turn off the burners on the stove when leaving home B. Can't remember what they did yesterday C. Continually misplace items D. Forgets what they had for breakfast

A

The nurse is discharging a client diagnosed with Parkinson's Disease. What would best help the client maintain their independence? A. Use of slip-on shoes, velcro closures, or no zippers on clothing B. Having spouse perform difficult tasks such as tying shoes and buttons C. Offer to provide hospital gowns to wear at home D. Encourage client to wear pajamas all day

A

The nurse is providing discharge instruction to a client diagnosed with cirrhosis. Which client statement would indicate understanding of the teaching? A. I will avoid the use of NSAIDS B. Wine will be better than liquor when I choose to drink C. Once I feel better, I won't have any more problems D. I should eat a low protein diet

A

The nurse is teaching a client about risk factors for stroke. What statement by the client would indicate the need for further teaching? A. I want my blood pressure high to provide blood to my brain B. I should try to walk every day C. I need to watch how many fats I eat D. I should limit how much alcohol I drink

A

The nurse is caring for a client recovering following a laparoscopic cholecystectomy. During the post-procedure assessment, the client reports referred pain to the shoulder. What statement should the nurse make? A. I will need to update the healthcare provider on this change in condition B. I can administer the hydromorphone 0.1 mg IV prn Q1h that has been ordered for you C. This can happen after laparoscopic surgery. Let's go for a walk D. This is not typical. Could you please describe what else you are experiencing?

C

The nurse is caring for a client with a gastric tube. What task would the nurse be able to delegate to the LPN they are working with? A. Assess for complications related to tubes and enteral feedings B. Evaluate nutritional status of a client receiving enteral feedings C. Provide skin care around gastrostomy tube D. Teach client and caregiver about home enteral feedings

C

The nurse is caring for a client with cholecystitis and bile duct obstruction. Which assessment finding should the nurse anticipate? A. Blood stools B. Heartburn C. Yellow skin and eyes D. Abdominal pain when eating low fat foods

C

The nurse is cussing effective self-management strategies with a client with GERD. What statement by the client demonstrates understanding? A. I will limit my fluid intake between meals B. I will eat three large meals a day C. I will not lay down for 2-3 hours after eating D. I will sleep in a flat position

C

The student nurse reports that black, sticky, foul-smelling stool was evident in the client's bed pan. How should the nurse document these findings? A. Hematemesis B. Hematochezia C. Melena D. Occult stool

C

What action should the nurse delegate to the UAP they are working with? A. Assess for neurovascular changes to the extremities B. Compare vital signs to baseline C. Assist the client to the restroom D. Monitor client for chest pain

C

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. Client has a history of clots B. Right-sided carotid bruit C. Blood pressure of 220/120 mmHg D. EKG shows atrial fibrillation

C

Which assessment finding is a priority for the nurse to report to the healthcare provider regarding a client diagnosed with acute pancreatitis? A. Uppera bdominal tenderness and guarding B. Nausea and vomiting C. Confusion and fruity smelling breath D. Hypotonic bowel sounds

C

Which assessment finding obtained by the nurse when assessing a client diagnosed with acute pericarditis should be reported immediately to the health care provider? A. Temperature 100.5 degrees Fahrenheit B. Blood pressure of 168/94 C. Jugular venous distention D. Chest pain when taking a deep breath rated 6/10

C

Which assessment finding should be reported to the healthcare provider? A. Pupil size is 3 mm with brisk constriction to light B. Bradoradialis reflex is 3+ bilaterally C. Decline in level of consciousness D. Midline protrusion of the tongue

C

Which information about dietary management should the nurse include when teaching a client with PUD? A. You should not eat anything until your ulcer heals B. You should avoid eating any raw fruits and vegetables C. Avoid foods that cause pain after you eat them D. High-protein foods are less likely to cause you pain

C

Which laboratory finding should the nurse expect in a client with acute pancreatitis? A. Decreased blood glucose B. Decreased amylase C. Increased lipase D. Increased serum calcium

C

Which statement by a client, after being taught about risk management of stroke, would require follow-up by the nurse? A. I need to watch my weight B. I will avoid fried food C. I need to switch to having beer instead of hard liquor D. I will walk regularly

C

A few days ago after exploring a myocardial infarction (MI) and successful percutaneous coronary intervention, the client states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be best for the nurse to make? A. Recovery from a heart attack takes months B. Not everything goes according to plan C. Where are you going on vacation? D. Tell me more about how you are feeling

D

A client diagnosed with Alzheimer's Disease is restless and agitated. Which initial intervention by the nurse would be most appropriate? A. Confront client about behavior B. Redirect the client to fold laundry C. Threaten use of restraints D. Give prescribed haloperidol prn

B

A client diagnosed with cirrhosis has a large amount of ascites. Which nursing intervention is a priority for the nurse to include in this client's plan of care? A. Restrict daily dietary protein intake B. Ensure that the client sleeps with the head of the bed elevated C. Reposition the client every 4 hours D. Make client NPO

B

A client reports gas pains and abdominal distention 2 days after a small bowel resection. What intervention should the nurse implement? A. Provide an enema B. Ambulation C. Offer the prescribed promethazine D. Administer the prescribed IV morphine sulfate

B

A client who has severe Alzheimer's Disease is being admitted to the hospital for surgery. Which intervention would be the priority for the nurse? A. Encourage the client to discuss events from the past B. Place the client on safety monitoring devices C. Reorient the client to the date and time every 2 to 3 hours D. Provide the client with current newspapers and magazines

B

A nurse cares for a client diagnosed with a spinal cord injury who develops autonomic dysreflexia. Which will the nurse expect to observe? A. Tachycardia B. Severe hypertension C. Increased temperature in the extremities D. Increased SOB

B

After receiving change-of-shift report on four clients, which client should the nurse assess first? A. Client diagnosed with rheumatic fever who has sharp chest pain with a deep breath B. Client diagnosed with acute aortic regurgitation whose BP is 86/54 C. Client diagnosed with infective endocarditis who has a murmur D. Client diagnosed with dilated cardiomyopathy who has bilateral crackles at the lung bases

B

The UAP is attempting to put an oral airway in the mouth of a client having a seizure. Which action should the nurse take? A. Help the UAP to insert the oral airway in the mouth B. Tell the UAP to stop trying to insert anything in the mouth C. Take no action because the UAP is handling the situation D. Notify the charge nurse of the situation immediately

B

The client diagnosed with a mild concussion is being discharged. What should the nurse include in the discharge teaching? A. Stress the importance of a good night's sleep B. Ensure someone will be able to stay with the client overnight C. Report heart rate > 100 bpm to the healthcare provider D. Resume driving per usual routine

B

The client has an intracranial pressure monitor in place 3 days ago post cranial surgery. Which information is most important to communicate to the health care provider? A. Pulse 92 bpm B. Temperature 101.6 C. Blood pressure 118/72 D. Respirations 22 bpm

B

The emergency department nurse is caring for a responsive adult client admitted with large volume hematemesis with the following vital signs: BP 94/68 HR 110 R 22 O2 93% on RA T 99.8 Based on this information and findings, which should the nurse implement first? A. Draw blood for coagulation studies B. Administer normal saline IV at 200mL/hr C. Place the client in the supine position D. Insert NG tube

B

The emergency department nurse is caring for an older client reporting persistent nausea and vomiting. Which intervention should be the priority interventions for the nurse? A. Clear liquid diet B. Normal saline intravenous at 75 ml/hr C. Bedrest with bathroom privileges D. Daily weight

B

The family of a client newly diagnosed with an ischemic stroke asks the nurse, "Why is their blood pressure still 190/86? Shouldn't the receive medication to decrease their blood pressure?" What is the best response by the nurse? A. Yes. This blood pressure should be treated immediately with medication B. No. This blood pressure is a protective response to maintain cerebral perfusion C. Yes. However, we should discuss risk factors for hypertension first D. No. Blood pressure like that are normal for someone their age

B

The nurse cares for a client diagnosed with bacterial meningitis who has a temperature of 102.5 degrees Fahrenheit and a severe headache. Which of the following should the nurse implement first? A. Adminsister ceftizoxime 1 g IV B. Draw blood cultures C. Give acetaminophen 650 mg PO D. Use a cooling blanket to lower temperature

B

The nurse cares for a client diagnosed with infective endocarditis. What finding should be most concerning to the nurse? A. New systolic murmur B. Temperature of 102 degrees Fahrenheit C. The client reports abdominal tenderness D. Reddish-purple pea-sized lesions on the fingertips

B

The nurse cares for a client newly diagnosed with a head injury. Which action would be a priority for the nurse to implement? A. Administer acetaminophen 650 mg orally B. Assess client's level of consciousness C. Assess the client's memory D. Ensure head of bed is at 30 degrees

B

The nurse cares for a client newly diagnosed with diverticulitis. Which statement by the client would indicate understanding of the teaching provided? A. I need to decrease the amount of fiber in my diet B. I should watch if I have blood in my stool and let my provider know C. I need to increase the amount of peanuts I eat D. I need to limit my activity so that my bowels can rest

B

The nurse cares for a client recovering 3 days post coronary artery bypass grafting (CABG) surgery who still has a chest tube. The nurse notes popping sensation when pressing on the client's skin. What action should the nurse perform? A. Initiate a rapid response B. Mark a line and continue to monitor C. Clamp the chest tube D. Elevate the drainage system to the level of the client's chest

B

The nurse cares for a client suspected of having an ST-elevation myocardial infarction (STEMI). Which laboratory value should the nurse monitor? A. Homocysteine B. Troponin C. Low-density lipoprotein D. B-type natriuretic peptide (BNP)

B

The nurse cares for a client with end stage Parkinson's disease. Which assessment finding should be most concerning to the nurse? A. No bowel movement in 2 days B. Coughing while eating C. Needs a cane to walk D. Tremors in the upper extremities

B

The nurse cares for a client with increased intracranial pressure with ICP monitoring. Which task can the nurse delegate to the UAP? A. Assess for safety risks in the room B. Check blood pressure every 4 hours C. Document intracranial pressure every hour D. Monitor cerebrospinal fluid color and volume hourly

B

The nurse cares for a client with symptomatic bradycardia. What intervention is the priority for the nurse? A. Call the provider B. Attach external pacing wires C. Administer scheduled metoprolol D. Call a code blue

B

The nurse cares for a patient with a suspected stroke. What is the priority intervention for this client? A. Draw blood to determine platelet levels B. Non-contrast computed tomography (CT) scan C. Administer IV alteplase D. 12-lead electrocardiogram (ECG)

B

The nurse is admitting a client diagnosed with infective endocarditis. What should be the priority intervention by the nurse? A. Administer ceftriaxone 1 g per day peripheral IV B. Draw blood cultures C. Give acetaminophen (Tylenol) PRN for fever D. Arrange for a transesophageal echocardiogram

B

The nurse is admitting a client with a prosthetic mitral valve who has suspected infective endocarditis. What question would be priority to ask? A. Have you smoked cigarettes recently? B. Have you had any recent dental procedures? C. Do you have any history of snorting cocaine? D. Do you participate in activities with soil, such as gardening?

B

The nurse is caring for a client diagnosed with mitral valve regurgitation. Which information obtained by the nurse when assessing the client is most important to urgently report to the health care provider? A. The client has 4+ peripheral eema B. Oxygen saturation 86% on room air C. The client has palpitations D. The client has thready peripheral pulses

B

The nurse is caring for a client recovering from a percutaneous coronary intervention (PCI) via the femoral artery. Which assessment finding should be a priority concern for the nurse? A. Pedal pulses +1 bilaterally B. Temperature 100.9 degrees Fahrenheit C. Blood pressure 100/54 mmHg D. Dried blood on insertion site dressing

B

The nurse is caring for a client who just returned from a carotid endartectomy. Which assessment finding should be of most concern to the nurse? A. Pulse rate of 90 bpm B. Difficulty speaking C. Blood pressure 110/88 D. 25 mL of blood in the JP drain

B

The nurse is caring for a client who reports a new onset of severe chest pain. What should be the priority intervention by the nurse? A. Check the client's vital signs B. Perform 12-lead ECG C. Assess if pain radiates to the jaw D. Auscultate heart sounds

B

The nurse is caring for a client with PUD. Which assessment finding should be most concerning to the nurse? A. Stomach pains after eating B. Abrupt, sudden onset of abdominal pain of a "9" C. Heart burn D. Black, tarry stools

B

The nurse is caring for a client with dementia. What question would best tell the nurse how the caregiver is handling their caregiver responsibilities? A. How has your life been negatively affected since the diagnosis? B. How are you handling caring for your spouse? C. What do you do to manage the wandering? D. Do you ever want to have them stay in an adult daycare?

B

The nurse is educating a client who is at risk for developing coronary artery disease. What statement by the client should tell the nurse more education is needed? A. I will increase the amount of exercise I am getting B. I will switch from smoking and chew tobacco instead C. I will limit the amount of red meat that I eat D. I will limit the amount of salt in my diet

B

The nurse is preparing to discharge a client who is recovering after placement of an implanted cardioverter-defribillator (ICD). What client statement would indicate that teaching was effective? A. I need to keep incision dry for one week B. I will avoid lifting arm on ICD side above my shoulder until I see my doctor C. I can't engage in sexual activity for two months after the surgery D. I need to only have a liquid diet for the next three days

B

The nurse is teaching a client with GERD ways to prevent symptoms. Which statement by the client would indicate that the teaching has been effective? A. I will lie down after eating to help move things through my system B. I will avoid caffeine and alcohol C. I will limit my fluid intake so my stomach doesn't get too full D. I should only eat 2-3 times per day

B

The nurse is teaching a client with acute pancreatitis about their lab findings. Which client statement would indicate the need for further education? A. I should look at my amylase levels B. I need to monitor my bilirubin levels C. My lipase levels will be high D. My blood sugar levels may be high while my pancreas heals

B

The nurse is teaching an alcoholic client about complications of cirrhosis and portal hypertension. What complication should the nurse include in the teaching? A. Gallstones B. Esophageal varices C. Pancreatitis D. Splinter hemorrhages

B

What is priority for the nurse to consider in a client suspected of having a stroke? A. Time of the client's last meal B. Time at which stroke symptoms first appeared C. Neurological symptoms D. Family history of stroke

B

The nurse receives the following information about for clients during change of shift report. Which client should the nurse assess first? A. A client diagnosed with diverticulitis who has small amounts of bloody stool B. A client recovering from a laparoscopic cholecystectomy who is reporting shoulder pain C. A client diagnosed with chronic pancreatitis who has abdominal pain D. A client diagnosed with cirrhosis and ascites who has an oral temperature of 102 degrees Fahrenheit

D

The nurse recognizes that client education about a laparoscopic cholecystectomy has been effective when the client makes which statement? A. I will need a NG tube for several days after my surgery B. I will need to be on bedrest for a few days after my surgery C. I can expect yellow-green drainage from the incision for a few days D. I may experience shoulder pain after the surgery

D

The nurse working on an inpatient gastrointestinal unit receives the following information during change of shift report. Which client should the nurse plan to assess first? A. Client diagnosed with upper gastrointestinal GI bleeding with melena B. Client admitted yesterday with cirrhosis with CIWA precautions in place who is sleeping C. Client reporting abdominal pain with 60 mL emesis in the last hour D. The client reporting pain radiating to the back with a rigid abdomen, HR of 130 bpm, and BP of 96/58 mmHg

D

The recovery room nurse cares for a client immediately following coronary angiogram with stent placement. What should be included in the client's plan of care? A. General diet B. HOB >30 degrees C. Discontinue continuous cardiac monitoring D. Maintain bed rest in supine position with extremity straight

D

What client would be priority for the nurse to assess? A. A client whose cranial x-ray shows a linear skull fracture B. A client who has an initial Glasgow Coma Scale score of 13 C. A client who lost unconscious briefly after a fall D. A client whose right pupil is 8 mm and unresponsive to light

D

When performing teaching for a client diagnosed with a transient ischemic attack (TIA) which statement by the client indicates understanding of the teaching? A. I got lucky. At least I won't have a stroke now B. I need to make sure my blood pressure doesn't get below 180 C. I need to avoid taking aspirin now D. I need to watch how many fatty foods I eat

D

Which client should the nurse see first? A. A client who has atrial fibrillation and a new order for subcutaneous heparin injection B. A client who experienced a transient ischemic attack yesterday and has a dose of aspirin due C. A client with a subarachnoid hemorrhage 4 days ago who is waiting for discharge instructions D. A client with right-sided weakness who has an infusion of tPA prescribed

D

Which statement by the client undergoing transesophogeal echocardiogram (TEE) indicates the need for further education? A. I may have a sore throat after this procedure B. I will remove my dentures now so I don't forget C. I will be monitored for return of my gag reflex after the procedure D. I will order breakfast quickly before going to the procedure in an hour

D

While caring for a client diagnosed with Amyotrophic Lateral Sclerosis, what is the priority assessment for the nurse? A. Monitor sensory function of the extremities B. Determine level of consciousness C. Check strength of extremities D. Observe respiratory rate and effort

D

A client's heart monitor shows a pattern of no measurable ECG pattern. The client is unconscious, apneic, and pulseless. Which action should the nurse take first? A. Apply oxygen per nasal canula B. Ensure IV patency to administer a beta blocker C. Assess the client's blood pressure D. Begin CPR

D

A client diagnosed with an acute exacerbation of ulcerative colitis reports abdominal pain, cramping, and the passing of 15 or more bloody stools per day. Which provider order should the nurse question? A. Labs; CBC and type and cross match B. Give packed RBCs if hemoglobin is less than 9 gm/dL C. Intake and output D. Cap IV

D

A client is diagnosed with myocardial infarction, the EKG monitor shows atrial fibrillation. Which should be the priority intervention by the nurse? A. Provide emotional support to the client B. Prep the client for a pacemaker insertion C. Ask the client how long this has been going on D. Assess the client's response to the dysrhythmia

D

The nurse is providing discharge instructions to a client diagnosed with acute coronary syndrome. What should the nurse include in the teaching? Select all that apply A. Signs and symptoms of myocardial infarction B. When and how to seek help for symptoms C. Importance of pushing physical limits D. When to take prescribed nitroglycerine E. Necessary to not perform any physical activity

A, B, D

Which assessment finding by the nurse caring for a client who has had percutaneous coronary intervention using the right radial artery would be priority to report to the provider? A. Small area of blood on the dressing B. Pallor and weakness on the right hand C. Client does not keep arm at heart level D. Fine crackles heard at both lung bases

B

Which client should the nurse assess first after receiving report on the cardiac unit? A. A client diagnosed with a myocardial infarction two days ago with an elevated troponin B. A client diagnosed with cardiac tamponade with jugular venous distention C. A client diagnosed with chronic heart failure who has bilateral peripheral edema D. A client diagnosed with myocarditis with increased fever

B

A client admitted 3 days ago reports chest pain that increases when taking a deep breath and is relieved when leaning forward. What is the best action for the nurse to take? A. Assess the patient for pedal edema B. Palpate the radial pulses bilaterally C. Auscultate for a pericardial friction rub D. Check the heart monitor for dysrhythmias

C

A client has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which intervention should the nurse implement first? A. Insert a NG tube B. Provide oral care with moistened swabs C. Infuse normal saline at 250 mL/hr D. Administer IV ondansetron

C

A client is admitted with following a fall. Which assessment finding should be most concerning to the nurse? A. Pupils 4 mm, equal, and reactive to light B. Respirations 22 breaths per minute C. Confusion when asked the date and time D. Decreased sensation in extremities

C

After experiencing a myocardial infarction, the client is referred to cardiac rehab. Which statement by the client would indicate the need for further teaching? A. I will tell the rehabilitation team if I experience any chest pain B. I will need to alter my diet so that I have less fat in it C. I should try to walk 5 miles per day D. I will need to work with the team to increase my activity levels

C

An elderly client is diagnosed with a subdural hematoma. Which assessment finding by the nurse would first indicate neurologic worsening? A. Sternal rub needed to arouse client B. Muscle faccidity C. Increased lethargy D. Fixed, dilated pupil

C

During assessment of a client diagnosed with traumatic brain injury (TBI), the nurse notices a fixed, unilaterally dilated pupil. What is the most appropriate initial nursing action? A. Notify the healthcare provider B. Assess motor function C. Assess LOC D. Raise the head of the bed 15 degrees

C

The client is admitted to the medical-surgical unit with suspected cholelithiasis. What statement by the nurse is correct? A. You will have to watch how many green vegetables you are eating now B. Your symptoms will go away on their own and shouldn't return C. You will need to have an ultrasound done to see if you have gallbladder problems D. The x-ray technician will be here soon for a portable abdominal x-ray

C

The medical surgical nurse is admitting a client newly diagnosed with a stroke from the emergency department. The client asks the nurse for a drink of water. What action should the nurse take? A. Give the client a drink of water B. Position head of bed at a 45 degree angle to give a drink C. Make the client NPO until a swallow study is performed D. Thicken water

C

The nurse cares for a client diagnosed with an ischemic stroke who's symptoms began 4 hours ago. What order should be priority for the nurse to implement? A. Diet: NPO B. NIH stroke scale every 2 hours C. Alteplase IV D. Activity: bedrest

C

The nurse cares for a client diagnosed with severe hepatic encephalopathy due to cirrhosis. Which order should the nurse question? A. Ammonia levels daily B. Lactulose 15 mL every 8 hours C. Activity up ad lib D. Reposition client every hour

C

The nurse cares for a client following a percutaneous coronary intervention. Which intervention may be delegated to the LPN? A. Assess for allergies B. Monitor client for chest pain C. Give ordered dose of oral atorvastatin D. Teach client about signs of infection

C

The nurse cares for a client newly admitted with an ischemic stroke. Which order should the nurse question? A. Activity bedrest B. Diet: NPO C. Labetolol 20 mg IV prn to keep systolic blood pressure under 160 D. Physical therapy evaluation

C

The nurse cares for a client reporting persistent nausea and vomiting for the last several weeks. Which finding should be most concerning to the nurse? A. pH 7.47 B. Serum creatinine 0.8 mg/dL C. Potassium 2.7 mEq/L D. Urine output 40 mL/hr

C

The nurse cares for a client with gullain-barre syndrome. Which procedure should the nurse prepare the client for? A. Blood transfusion B. Deep brain stimulation C. Plasmapheresis D. Head CT

C

The nurse cares for a client with suspected meningitis. What procedure should the nurse prepare the client for? A. CT scan B. MRI C. Lumbar puncture D. EEG

C

The nurse cares for a client with suspected ulcerative colitis. What action by the nurse would be necessary before their diagnostic test? A. Insert an NG tube B. Administer a beta blocker prior to the procedure C. Administer bowel prep prior to the procedure D. Educate the client they may have a sore throat after the procedure

C

The nurse cares for an elderly client with a history of angina experiencing gastrointestinal upset and vomiting. What provider order should the nurse implement first? A. Ondansetron 4 mg IV now B. Nitroglycerine 0.4 mg sublingual every 5 minutes x3 C. EKG stat D. Cardiac enzymes stat

C

The nurse explains acute pancreatitis to a client newly diagnosed with the condition. The client asks the nurse what they can eat for dinner. How should the nurse respond? A. You will be placed on a soft diet that will allow you to transition to a general diet B. You will be placed on a general diet to promote intake C. You will not be able to eat for now D. You will be placed on a clear liquid diet to reduce gastric distention

C

The nurse is caring for a client experiencing alcohol withdrawal. What intervention should the nurse question? A. Bedrest B. Chlordiazepoxide (Librium) 50 mg PO as needed for agitation C. Activity up ad lib D. CIWA protocol

C

The nurse is caring for a client following a paracentesis. Which intervention should the nurse question? A. Check dressing for bleeding or leakage of ascetic fluid B. Monitor vital signs every fifteen minutes for the first hour C. Maintain strict bedrest for 1 week after procedure D> Monitor for changes in LOC

C

The nurse is caring for a client post coronary artery bypass graft (CABG) surgery. Which task should the nurse delegate to the Liscensed Practical/Vocational Nurse (LPN/LVN) they are working with? A. Administer dose of intravenous Furosemide B. Assess heart sounds C. Give dose of subcutaneous insulin D. Evaluate teaching on postoperative exercise

C

The nurse is observing a client during a tonic-clonic seizure. What priority action should the nurse perform? A. Administer prescribed intravenous lorazepam B. Insert an oral airway C. Record the details of the seizure D. Restrain the client

C

The nurse is providing discharge education to a client who underwent open hernia repair. Which client statement would indicate understanding of the teaching? A. I should limit dietary fiber intake to 20 grams/day B. I need to apply a warm compress to my abdomen C. I shouldn't lift more than 20 pounds D. I should take a warm bath when I get home

C

The nurse observes the student nurse assessing a client with a nasogastric tube. Which action by the student should the nurse correct? A. Turning off the suction while assessing bowel sounds B. Examining the back of the patient's throat for irritation C. Auscultating the abdomen for tube placement D. Keep head of the bed elevated

C

The nurse on a medical surgical unit is caring for several clients. Which client would the nurse assess first after receiving report? A. Client diagnosed with a concussion who is complaining someone is waking them up every two hours B. Client admitted with report of right-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan C. Client admitted with blunt trauma to the head after a motorcycle rash who has a Glasgow Coma Scale (GCS) score of 6 D. Client diagnosed with a stroke who has expressive aphasia

C

The nurse on the medical-surgical unit is assigned to four patients. Which client should be assessed first? A. Client diagnosed with a basilar skull fracture who has a bruise behind the hear B. Client diagnosed with an ischemic stroke 3 days ago who has right sided facial droop C. A newly admitted client with a traumatic brain injury who has a respiratory rate of 34 breaths per minute D. Client who is 3 days postoperative after a craniotomy and reports nausea

C

The nurse performs an initial assessment for a client admitted to the medical-surgical unit following ileostomy placement. Which assessment finding should be most concerning for the nurse? A. Excessive gas in bag B. Moderate edema round stoma site C. Purple colored stoma D. Small amount of blood oozing from stoma when touched

C

The nurse teaches a client about risk factors for coronary artery disease. Which statement by the client would indicate that teaching was effective? A. I need to be careful with how much I exercise B. I shouldn't smoke more than 1-2 cigarettes per day C. I need to watch my cholesterol levels D. I'm glad that I won't have a heart attack like my grandfather did

C

A client with a new diagnosis of chronic stable angina is being discharged from the cardiac telemetry unit. Which statement by the client would indicate the need for further education? A. If I have pain, I should rest to see if it goes away B. I might need to take nitroglycerine pills for the pain C. Exertion and anxiety can trigger the pain D. The pain usually lasts longer than 20 minutes

D

A client diagnosed with a stroke 2 days ago is reporting a severe headache. What should be the priority action by the nurse? A. Assess pain and administer acetaminophen as ordered B. Prepare to administer alteplase IV C. Start an intravenous infusion with D5W at 100 mL/hr D. Complete a neurological assessment

D

After receiving change-of-shift report about the following four clients on the cardiac care unit, which client should the nurse assess first? A. A client with acute pericarditis with sharp chest pain B. A client with angina who is scheduled to receive nifedipine (Procardia) C. A client who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge D. A client with unstable angina who has just returned to the unit after a percutaneous coronary intervention (PCI)

D

After receiving report on a cardiac unit, which client should the nurse assess first? A. Client six hours post coronary artery bypass graft (CABG) who has 50 mL of sanguineous drainage in the chest tube collection system B. Client who is recovering following angioplasty via the femoral artery and with blood identified underneath the client's back when turning the patient C. Client diagnosed with acute myocardial infarction two days ago with report of chest pain with inspiration D. Client just returning from percutaneous cardiac intervention with no pulse in extremity

D

The emergency department nurse cares for a client with abdominal pain. After starting an IV catheter, the nurse obtains the following vital signs: BP: 88/54 HR: 134 RR: 32 SpO2: 92% on 2L O2 per nasal cannula T: 100.9 Fahrenheit What is the priority action for the nurse? A. Place indwelling urinary catheter B. Administer 350 mg Acetaminophen PO C. Draw blood for CBC and electrolyte levels D. Start normal saline infusion

D

The emergency room nurse cares for a client suspected of having a myocardial infarction. What should be the priority interventions by the nurse? A. Establish IV access B. Administer nitroglycerine C. Draw labs D. Perform an electrocardiogram (EKG)

D

The nurse cares for a client diagnosed with a anterior basilar skull fracture. Which order should the nurse question? A. Neuro assessment every 1 hour B. Halo test of nasal drainage C. Maintain bedrest D. Insert NG tube

D

The nurse cares for a client diagnosed with an ST elevation myocardial infarction. What intervention should the nurse implement first? A. Administer sublingual nitroglycerine B. Draw cardiac enzymes C. Administer intravenous morphine D. Prepare the client for cardiac catheterization

D

The nurse cares for a client who experienced a stroke with damage to the right frontal lobe. Which of the following would be a priority intervention for the nurse to implement? A. Place food on unaffected side of client B. Develop a method to communicate with the client C. Provide reassurance to the client regarding their disability D. Assist the client with ambulation

D

The nurse cares for a client who fell off of a ladder. While assessing the client, the nurse notices clear fluid draining from the nose. What provider order should the nurse question? A. Neuro assessments every hour B. Keep room lights low C. Assist the client with ambulation D. Insert nasogastric tube to low intermittent suction

D

The nurse cares for a client who had coronary artery bypass grafting (CABG) one week prior and is getting discharged. Which client statement would indicate that discharge teaching was effective? A. I can expect oozing from my incision for the next month B. I really need to avoid a lot of activity from now on C. I'm going to stop drinking vodka and drink beer instead D. I will need to minimize the amount of fat in my diet from now on

D

The nurse cares for a client with a suspected abdominal aortic aneurysm. Which assessment finding should be most concerning for the nurse? A. Chest pain with activity B. Absent pedal pulses C. Abdominal pain D. Low back pain

D

The nurse cares for a client with cirrhosis and ascites. What procedure should the nurse prepare the client for? A. Colonscopy B. Liver biopsy C. Endoscopic retrograde cholangiopancreatography (ERCP) D. Paracentesis

D

The nurse cares for a client with gastric ulcers and suspected perforation. Which assessment finding would be most concerning to the nurse? A. Pain after eating B. Temperature 100.9 degrees Fahrenheit C. Melena stools D. Rigid, boardlike abdomen

D

The nurse cares for a client with suspected valvular disease. Which procedure should the nurse prepare the client for? A. Coronary artery bypass grafting (CABG) B. Percutaneous coronary angiography C. Cardiac ablation D. Transesophageal echocardiogram (TEE)

D

The nurse is caring for a client diagnosed with chronic pancreatitis. Which statement by the client would indicate the need for further teaching? A. I will need to have TPN for awhile while I heal B. I need to make sure the dressing on my PICC line is changed each week C. I shouldn't eat while my pancreas is inflamed D. I should only drink beer now instead of vodka

D

The nurse is caring for a client with Parkinson's disease. Which statement by the client would indicate the need for further teaching? A. I should wear clothing with elastic bands to help get myself dressed B. I can get a recliner that lifts up so I can get up easier C. I should remove rugs so I don't trip over them D. I need to stay in bed all the time so I don't fall

D

The nurse is caring for a client with chronic GERD and difficulty swallowing. Which test should the nurse prepare the client for? A. Colonoscopy B. ERCP C. EGD D. Barium swallow study

D

The nurse is caring for a client with chronic stable angina. Which statement by the client would require further education? A. I can skip my medication if I don't have chest pain B. If I develop chest pain, I should try to rest C. If my chest pain doesn't go away with rest, I should take a nitroglycerine D. I should call 911 if my chest pain doesn't go away after nitro pills

D

The nurse is caring for a client with end stage cirrhosis. Which statement by the client would indicate a need for further education? A. I should take my lactulose to prevent confusion B. I will have yellow skin with my disease C. I can't drink alcohol anymore D. I can eat potato chips for nutrition

D

The nurse is caring for a client with suspected pancreatitis. Which assessment findings should the nurse anticipate? A. Chronic pain that is relieved by vomiting and not affected by eating B. Recent onset of pain that is intermittent in the right lower quadrant C. Long term pain in the right upper quadrant that is better after drinking milk D. Upper abdominal pain that occurs right after eating

D

The nurse is completing the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) on a client experiencing alcohol detoxification. What assessment finding should be most concerning to the nurse? A. Constant headache of a "5" B. Visual hallucinations C. Fine tremors of the fingers D. Blood pressure 180/100

D

The nurse is educating a client who will be undergoing an electroencephalogram. What statement about the procedure is accurate? A. Needle electrodes are inserted into the muscle to record specific activity B. Conduction velocity of peripheral nerves are measured C. Radiolabeled compounds are injected and imaging is obtained D. Electrical activity of the brain is recorded using scalp electrodes

D

The nurse is planning care for a client diagnosed with acute severe pancreatitis. Which of the following is the highest priority for this client? A. Satisfaction with pain control B. Maintenance of oral intake C. Glucose monitoring D. Maintenance of normal respiratory function

D

The nurse is reviewing the chart of a client admitted to the unit diagnosed with GERD. Which manifestations should the nurse anticipate? A. Left lower quadrant pain B. Hematochezia C. Palpitations D. Chest pain after eating spicy food

D

The nurse is watching a student provide care for a client with a complete T4 spinal cord injury. Which action by the student should the nurse question? A. Assessing sensation in the lower extremities B. Asking the client about motor function C. Taking the client's blood pressure D. Applying a heating pad to the client's lower extremities

D

The nurse is working with a client who has just returned from a cardiac ablation. What should the nurse delegate to the LPN they are working with? A. Assess client's vital signs B. Educate the client about their medications C. Evaluate client's pain level D. Administer oral amiodarone

D