Exam 4

The nurse is conducting a functional assessment for an older adult client. The client reports to the nurse, "I often forget where I put my keys, but that is expected at my age." Which of the following is the most appropriate response by the nurse? a. "How often do you think you forget where items are located?" b. "Yes, short term memory loss does occur as you get older." c. "What do you do to remember where your keys are?" d. "I lose my keys all the time, as long as you find the keys it is not a problem."

"How often do you think you forget where items are located?"

The nurse is providing pre-operative teaching regarding autologous blood transfusion to a 60-year old client in preparation for surgery. Which of the following statements by the client would indicate correct understanding of the teaching? a. "I do not think I can develop a reaction if I receive my old blood." b. "I need to donate blood for the transfusion 5 weeks before my surgery." c. "I cannot receive autologous transfusion since I am a Jehovah's Witness." d. "I cannot donate blood for autologous transfusion because of my age"

"I need to donate blood for the transfusion 5 weeks before my surgery."

The nurse is teaching a client who is postoperative abdominal surgery the purpose of the incentive spirometer. Which of the following statements by the nurse would indicate a correct understanding of the procedure? a. "The spirometer can help you cough out the secretions in your lungs." b. "The spirometer can prevent formation of blood clots in your lungs." c. "The spirometer can prevent the development of fever after surgery." d. "The spirometer can help the expansion of your lungs after surgery."

"The spirometer can help the expansion of your lungs after surgery."

The nurse in the ambulatory surgical center is assessing a client scheduled for surgery requiring general anesthesia. The client states, "I ate a light breakfast about 2 hours ago." Which of the following statements by the nurse would be appropriate? a. "You may experience more nausea than usually expected after the surgery." b. "We will have to wait another two hours to do your surgery." c. "We will give you medication to prevent you from vomiting during the surgery." d. "There is a possibility that your surgery will be rescheduled."

"There is a possibility that your surgery will be rescheduled."

The evening shift nurse received report that a signed consent is needed before the client goes to surgery in the morning. The nurse was not present when the surgeon explained the procedure to the client. Which of the following statements by the nurse would be most appropriate before asking the client to sign the consent form? a. "You have the right to change your mind at any time." b. "What were you told about your surgical procedure?" c. "Do you have any questions about your surgery tomorrow?" d. "Your surgeon asked me to ensure that you sign the consent form."

"What were you told about your surgical procedure?"

The nurse is collecting the health history of a client who reports daytime drowsiness. Which of the following statements would indicate to the nurse that the client is experiencing restless leg syndrome? a. "When I lie down at night, I feel like I need to keep moving my legs." b. "My legs feel heavy in the morning." c. "If I keep my legs still, the crawling sensation goes away." d. "I noticed that the color of my toes often change color."

"When I lie down at night, I feel like I need to keep moving my legs."

The nurse is assessing a client who has Parkinson's disease. Which of the following findings should the nurse expect with this client? a. Flaccid muscles b. Bradykinesia c. Dry skin d. Xerostomia

Bradykinesia

The nurse is caring for a client who had an open reduction internal fixation 2 hours ago to correct a fractured hip. Which of the following assessment findings would require immediate follow-up? a. Pain rated 6 on a scale of 0-10 b. Hemovac drainage of 125 mL c. Poor nutritional status d. Absence of leg immobilizer

Hemovac drainage of 125 mL

A nurse is assessing a client who has rotator cuff injury. Which of the following findings should the nurse expect to observe? a. Inability to maintain abduction of the arm at the joint. b. Difficulty performing circumduction of the joint c. Unable to shrug shoulders. d. Alteration in the contour of the joint.

Inability to maintain abduction of the arm at the joint.

The nurse is performing a neurological assessment for a client with a head trauma. Which of the following actions by the nurse would assess the function of the client's cranial nerve III. a. Have client stand with eyes closed and touch their nose. b. Ask the client to shrug shoulders against passive resistance. c. Instruct the client to look up and down without moving their head. d. Observe the client's ability to smile and frown.

Instruct the client to look up and down without moving their head.

The evening shift nurse is caring for a client who is scheduled for surgery. The client states "I once got a rash from wearing rubber gloves." Which of the following actions should the nurse take? a. Notify the operating room staff that the client has an allergy to sulfur-containing products. b. Notify the surgeon so that the surgery can be cancelled. c. No intervention is needed since the client will not be wearing gloves. d. Note in the medical record that the client has a latex allergy.

Note in the medical record that the client has a latex allergy.

The nurse is reviewing the laboratory data of a client with rheumatoid arthritis who is taking prescribed methotrexate. Which of the following results would indicate to the nurse the client is experiencing an adverse effect of the medication? a. Blood glucose of 125 d/L b. ALT of 30 U/L c. WBC of 10,000 mm3 d. Platelet count of 100 μL

Platelet count of 100 μL

The nurse in the post-anesthesia care unit (PACU) is caring for a female client who had an abdominal cholecystectomy. The client states "I think I am going to vomit." Which of the following interventions should the nurse perform? a. Position the client in the lateral recumbent position. b. Tilt the client's head back and elevate the jaw. c. Administer beta-adrenergic drugs as prescribed. d. Increase the client's IV fluids

Position the client in the lateral recumbent position.

The nurse is caring for a client who is postoperative appendectomy who has a prescription to ambulate. Which of the following actions should the nurse take first before ambulating the client? a. Position the client on the side of the bed b. Provide the client with additional oral fluids c. Have the client do deep breathing exercises d. Encourage the client to stand up quickly to alleviate abdominal pain.

Position the client on the side of the bed

A client has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The client receives a regular diet tray b. Staff have turned off the lights in the client's room c. Staff have entered the client's room without a mask d. The bedrails on both sides of the bed are elevated

Staff have entered the client's room without a mask

Which action will the nurse take when caring for a client with osteomalacia? a. Emphasize the importance of sunscreen use when outside b. Educate about the need for weight-bearing exercise c. Teach about the use of vitamin D supplements d. Discuss the use of medications such as bisphosphonates

Teach about the use of vitamin D supplements

When assessing a 53-yr-old client with bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention? a. The client has a positive Kernig's sign b. The client exhibits nuchal rigidity c. The client's temperature is 101° F (38.3° C) d. The client's blood pressure is 88/42 mm Hg

The client's blood pressure is 88/42 mm Hg

The nurse is assessing a client with a spinal cord injury following a skiing accident. Which of the following techniques should the nurse use to test the function of the spinothalamic tract? a. ask the client to push the lower extremity against an opposing force b. apply light pressure from a sharp object to the client's lower extremity c. strike the client's patella tendon with a hammer d. instruct the client to perform straight leg raise

apply light pressure from a sharp object to the client's lower extremity

The nurse is assessing a client who has a suspected right hip fracture following a fall. Which of the following findings would require immediate follow up by the nurse? a. edema and ecchymosis over the right hip b. diminished pedal pulse and capillary refill greater than 3 seconds in affected extremity c. right leg appears shorter than the left leg and client reports pain level of 6 d. adduction of the affected extremity is noted

diminished pedal pulse and capillary refill greater than 3 seconds in affected extremity

When obtaining a health history and physical assessment for a 36-yr-old female client with possible multiple sclerosis (MS), the nurse should: a. inquire about urinary tract problems b. inspect the skin for rashes or discoloration c. assess for the presence of chest pain d. ask the client about any increase in libido

inquire about urinary tract problems

The nurse advises a client with myasthenia gravis (MG) to: a. anticipate the need for weekly plasmapheresis treatments b. perform physically demanding activities early in the day c. do frequent weight-bearing exercise to prevent muscle atrophy d. protect the extremities from injury due to poor sensory perception

perform physically demanding activities early in the day