Med/Surg Nclex PN 3000

For a client with an endotracheal (ET) tube, which nursing action is most essential?

1. Auscultating the lungs for bilateral breath sounds

An 86-year-old client with a history of atrial fibrillation takes 5 mg of warfarin (Coumadin) daily. Warfarin therapy makes the client at risk for which complications?

2. Hemorrhage 3. Hepatitis 5. Hematuria

A client with bladder cancer has had his bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude?

2. The pouch faceplate doesn't fit the stoma.

A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Data collection findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. This data may reflect that:

2. the client is going into cardiogenic shock.

A client with atopic dermatitis is prescribed a potent topical corticosteroid. To address a potential client problem associated with this treatment, the nurse helps formulate the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, which "related-to" phrase should be added?

3. Related to percutaneous absorption of the topical corticosteroid

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:

3. wear gloves when caring for the client and wash her hands after touching the client.

A client is admitted to the medical-surgical floor with a suspected diagnosis of acute myeloid leukemia. A nurse discusses the client's condition in the hallway. This action by the nurse jeopardizes which of the following principles?

4. Confidentiality

An obese Hispanic client, age 65, is diagnosed with type 2 diabetes mellitus. Which statement about diabetes mellitus is true?

4. Diabetes mellitus is three times more common in Hispanics than in Blacks or Whites.

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse's suspicions are:

4. drop in blood pressure and rise in heart rate.

The physician has ordered digoxin for a client with pulmonary edema. The nurse knows that digoxin has a direct and beneficial effect on myocardial contraction in the failing heart. This effect:

4. slows the conduction of impulses through the atrioventricular (AV) node.