NRSG 1125 PrepU Clinical Judgement

A client comes to the clinic reporting urinary symptoms. Which statement would most likely alert the nurse to suspect benign prostatic hyperplasia (BPH)?

"I've had trouble getting started when I urinate, often straining to do so."

Which client statement would lead the nurse to suspect that the client is experiencing bacterial conjunctivitis?

"My eyelids were stuck together this morning."

A client with multiple myeloma reports uncomfortable muscle cramping. Which nursing interventions will the nurse implement in response to the client's report of symptoms? Select all that apply.

1. Encourage hydration 2. Encourage ambulation

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?

10 to 15 minutes

The nurse is preparing to administer a chemotherapy infusion to a client with esophageal cancer. The client has an implanted port that was last accessed 7 days ago. The insertion site is clean and dry and without erythema. Which is the appropriate action by the nurse?

Access the port using a Huber needle.

On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as:

Acute angle-closure.

The nurse is evaluating the laboratory values of a client whose nursing diagnosis is "risk for impaired skin integrity." Which of the following values places the client at greatest risk?

Albumin, 1.5 g/dL

The advanced practice psychiatric mental health registered nurse is leading a support group for adolescents who have recently experienced disruptions in their life. What participant most warrants further assessment for posttraumatic stress disorder?

An adolescent who has committed uncharacteristic acts of violence since the death of the adolescent's mother

Which is a potential complication of a low pressure in the endotracheal tube cuff?

Aspiration pneumonia

A nurse provides evening care for a client wearing a continuous telemetry monitor. While the nurse is giving the client a back rub, the client 's monitor alarm sounds and the nurse notes a flat line on the bedside monitor system. What is the nurse's first response?

Assess the client and monitor leads.

The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color?

Black

A patient admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek sign. What deficit does the nurse suspect the patient has?

Calcium

A client's caretaker calls the home care nurse and states accidentally puncturing the central venous catheter after discontinuing the total parenteral nutrition. What instructions should the nurse provide to the caretaker?

Clamp the catheter.

The nurse is reviewing the physician's order written for a postmenopausal client: "calcitonin salmon nasal spray 200 IU, one spray every day." What is the appropriate action to be taken by the nurse regarding this order?

Clarify with the physician that the spray should be given in only one nostril per day.

Which value does the nurse recognize as the best clinical measure of renal function?

Creatinine clearance

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour?

Cyanosis

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule.

A client is diagnosed with posttraumatic stress disorder (PTSD). Which finding would the nurse most likely assess?

Diaphoresis

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?

Dilute the liquid preparation with another liquid such as juice and drink with a straw.

The nurse obtains a client's oral temperature reading of 36.8°C (98.24 F). How should the nurse proceed?

Document the client's temperature result as obtained.

The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?

Extravasation

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?

Facial distortion and pain

A patient is receiving omalizumab to treat allergic asthma, which is not relieved by inhaled corticosteroids. Which nursing intervention is appropriate with each dose administration of omalizumab?

Have epinephrine available

The nurse is performing the history and physical examination on a client who is being admitted for anorexia nervosa. The client, a 23-year-old, is 5 feet 2 inches, and weighs 88 pounds. The nurse assesses the client's history of weight gain and loss, typical daily food intake, electrolyte and other blood studies, and elimination patterns. The nurse observes typical physical findings such as dry skin, lanugo, and brittle hair and nails. Which factor is a priority for the nurse to assess next?

Heart rate and rhythm

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns?

Identification by the destruction of the dermis and epidermis

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?

Increase the force of myocardial contraction

The nurse is evaluating the morning blood glucose results from the laboratory of several 1-day-old infants. Which result should the nurse prioritize for further action?

Infant C - 48 mg/dL

The nurse is caring for a patient in the oliguric phase of acute kidney injury (AKI). What does the nurse know would be the daily urine output?

Less than 400 mL

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?

Maintaining the airway

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?

Measure blood glucose concentration every 4 to 6 hours

After receiving large doses of an ovulatory stimulant such as menotropins, a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. Based on this assessment, what should the nurse do next?

Notify the healthcare provider.

A two-day postoperative client's temperature was 98.5°F (36.9°C) at 3:00 pm. At 6:00 pm, the unlicensed assistant (UAP) notifies the nurse that the client's temperature is 102°F (38.9°C). Which action should the nurse take?

Notify the physician.

Which assessment would a nurse perform on a client with Cushing's syndrome who is at high risk of developing a peptic ulcer?

Observe stool color.

The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide?

Potassium level of 3.1

Which situation would require the nurse to use critical thinking and decision-making skills in providing genetics-related nursing care?

Providing fertility counseling to a young family with a 2-year-old child with cystic fibrosis

The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first?

Pulse oximetry

The NATO triage system uses color-coded tagging to identify severity of injuries. A patient with survivable but life-threatening injuries (i.e., incomplete amputation) would be tagged with which color?

Red

When working with a client with diffuse scleroderma who is exhibiting a 'stone face' expression, the nurse should consider which of these to be a priority nursing diagnosis for this client?

Risk for aspiration related to swallowing impairments.

A patient is prescribed daily doses of phenytoin for seizures. The nurse knows that a single dose should not be missed during the course of treatment. Which condition could result if a dose is missed?

Status epilepticus

Which characteristics of a cherry angioma should be considered suspicious?

Sudden collection of several papules

What is the action of codeine when used to treat a cough?

Suppressant

Which is an effect of aging on upper and lower urinary tract function?

Susceptibility to develop hypernatremia

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?

Three hours

When the nurse questions the blood glucose level obtained via a glucometer, a serum blood level is ordered. This protocol is directed toward ensuring which measure of standardization?

Validity

A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing?

Vitamin K deficiency

A client has just returned to the unit following abdominal surgery and is in significant pain. According to the nursing process, how frequently will the nurse perform assessments on this client?

as often as needed

What are important nursing priorities on the first postoperative day for a client who has had an open reduction and internal fixation (ORIF) after a right hip fracture?

assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation

Which term describes the ability of the heart to initiate an electrical impulse?

automaticity

Which is the earliest and the most common symptom of endometrial cancer?

bleeding

A nurse is collecting objective data for a client with AIDS. The nurse observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa. What does this finding indicate?

candidiasis

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?

contractility

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?

neurogenic shock

The nurse is seeing a pregnant client who has a confirmed urinary tract infection that requires treatment. Which anti-infective medication should the nurse anticipate will be prescribed for this client?

nitrofurantoin

The nurse cares for a client with end-stage kidney disease (ESKD). Which acid-base imbalance is associated with this disorder?

pH 7.20 PaCO2 36 HCO3 14-

A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:

premature closure.

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?

wheezes with wet lung sounds

Over the past 2 months, a client has been receiving treatment for multiple ear infections and tonsillitis. The client reports vaginal discharge and itching. What is likely the cause of the client's vaginitis?

• antibiotics

A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor?

Decreased level of erythropoietin

The nurse working on a cancer treatment floor assesses her assigned clients. It is most important for the nurse to report which assessment finding?

Coolness and mottling of a newly constructed breast site

The nurse prepares to apply ECG electrodes to a male client who requires continuous cardiac monitoring. Which action should the nurse complete to optimize skin adherence and conduction of the heart's electrical current?

Clip the client's chest hair prior to applying the electrodes.