NCLEX: Physiological Integrity

A client is admitted to the cardiac intensive care unit after coronary artery bypass graft surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75ml. During the second hour, the drainage has dropped to 5mL. The nurse interprets that: 1. This is normal 2. The tube may be occluded 3. The lung has fully reexpanded 4. The client needs to cough and take deep breaths

2. The tube may be occluded

A client has undergone urinary diversion after cystectomy for bladder cancer. The nurse assesses the client's urostomy stoma to ensure that it shows which of the following characteristics? 1. It's pale and pink 2. It's pink and dry 3. It's red and moist 4. It is dusky to beefy colored

3. It's red and moist

A nurse is caring for a hospitalized client with a mechanical heart valve who is receiving maintenance therapy of warfarin sodium (Coumadin). The client's international normalized ration is 3. The nurse anticipates which of the following prescriptions? 1. Holding the next dose of warfarin sodium 2. Administering the next dose of warfarin sodium 3. Increasing the next dose of warfarin sodium 4. Adding a dose of heparin

2. Administering the next dose of warfarin sodium

A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse assesses the client for which of the following manifestations? 1. Weight loss 2. Bilateral crackles 3. Distended neck veins 4. Peripheral pitting edema

2. Bilateral crackles

A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? (SATA) 1. Weight loss 2. Bradycardia 3. Hypotension 4. Dry, scaly skin 5. Heat intolerance 6. Decreased body temperature

2. Bradycardia 3. Hypotension 4. Dry, scaly skin 6. Decreased body temperature

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse checks the ulcerated area for which of the following expected appearances? 1. Pale, cool, and dry skin surrounding the ulcer 2. Brown and edematous skin surrounding the ulcer 3. Pale, deep ulcer base 4. Brown ulcer base with no edema surrounding the ulcer

2. Brown and edematous skin surrounding the ulcer

A client with diabetes mellitus receives Humulin Regular insulin 8 units subcutaneously at 0730. The nurse would be most alert to signs of hypoglycemia at what time during the day? 1. 0930 to 1130 2. 1130 to 1330 3. 1330 to 1530 4. 1530 to 1730

1. 0930 to 1130

Which of the following clients with renal failure is best suited for peritoneal dialysis as a treatment option? 1. A client with severe congestive heart failure 2. A client with a history of ruptured diverticula 3. A client with a history of herniated lumbar disk 4. A client with a history of three previous abdominal surgeries

1. A client with severe congestive heart failure

A client becomes restless and agitated and complains of shortness of breath and palpitations. The nurse identifies on the cardiac monitor that the client is experiencing an atrial fibrillation with a rapid ventricular response. The nurse determines that which priority problem is most likely to occur? 1. A decrease in cardiac output 2. A breathing pattern that is not effective 3. Anxiety 4. A disruption in gas exchange in the alveoli

1. A decrease in cardiac output

The emergency service team brings a client to the emergency department. The client was found lying in an alley near a dumpster by a policeman, who reports that the client is a homeless victim. An assessment is performed, and the client is suspected of having frostbite of the hands. Which of the following findings would the nurse note in this condition? 1. A white appearance to the skin that is insensitive to touch 2. A pink edematous hand 3. Black fingertips surrounded by an erythematous rash 4. Red skin with edema in the nasal beds

1. A white appearance to the skin that is insensitive to touch.

A client has a Mantoux skin test done. The results indicate an area of induration that is 8mm in size. The nurse should make which interpretation based on this finding? 1. The client has active tuberculosis 2. The client has a negative response 3. the client has a history of tuberculosis 4. the client has been exposed to tuberculosis

2. The client has a negative response

The nurse provides information to a client with gastroesophageal reflux disease (GERD) about the factors that contribute to decreased lower esophageal sphincter (LES) pressure and worsen the condition. The nurse tells the client that which of the following factors contribute to decreased LES pressure? (SATA) 1. Alcohol 2. Fatty foods 3. Citrus fruits 4. Baked potatoes 5. Caffeinated beverages 6. Tomatoes and tomato products

1. Alcohol 2. Fatty foods 3. Citrus fruits 5. Caffeinated beverages 6. Tomatoes and tomato products

An emergency department nurse is performing an assessment on a client who has sustained circumferential burns of both legs. Which assessment would be the priority in caring for this client? 1. Assessing peripheral pulses 2. Assessing neurological status 3. Assessing urine output 4. Assessing blood pressure (BP)

1. Assessing peripheral pulses

A client sustained a penetrating eye injury from a piece of glass when a mirror with a metal backing in the client's bathroom fell and broke. On visual assessment of the injured eye, the nurse can see a piece of glass trudging from the eye. The nurse prepares the client for which interventions? (SATA) 1. Assessment of visual acuity 2. X-rays studies of the eye orbit 3. Administration of a tetanus booster 4. Immediate removal of the glass with forceps 5. Computed tomography (CT) scans of the orbit 6. Magnetic resonance imaging (MRI) of the eye orbit

1. Assessment of visual acuity 2. X-rays studies of the eye orbit 3. Administration of a tetanus booster 5. Computed tomography (CT) scans of the orbit

When assessing a client for possibly symptomology of Menière disease, the nurse should ask which questions? (SATA) 1. "Do you experience ringing in your ears?" 2. "Are you prone to vertigo that can last for days?" 3. "Can you hear better out of one ear than the other?" 4. "Is there a history of Meniere disease in your family?" 5. "Have you ever experienced a head injury in the area of your ears?"

1. "Do you experience ringing in your ears?" 2. "Are you prone to vertigo that can last for days?" 3. "Can you hear better out of one ear than the other?"

The nurse develops a discharge plan for a client who had a total abdominal hysterectomy. The nurse should include which activity instructions in the plan? (SATA) 1. Avoid heavy lifting 2. Sit as much as possible 3. Take baths rather than showers 4. Limit stair climbing to five times a day 5. Gradually increase walking as exercise but stop before becoming fatigues 6. Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks

1. Avoid heavy lifting 4. Limit stair climbing to five times a day 5. Gradually increase walking as exercise but stop before becoming fatigues 6. Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks

A nurse is caring for the client who has jut had a precipitate delivery. Before attempting to deliver the placenta, the nurse waits for which of the following signs as an indication of placental separation? 1. Change in uterine shape 2. Sudden abdominal pain 3. Shortened umbilical cord 4. Decreased blood flow from the introitus

1. Change in uterine shape

The nurse monitors a client with a pelvic fracture sustained in an automobile crash for signs of fat embolism syndrome. Which of the following manifestations are indicative of his complication? (SATA) 1. Dyspnea 2. Chest pain 3. Bradypnea 4. Badycardia 5. Lung crackles 6. Altered mental status

1. Dyspnea 2. Chest pain 5. Lung crackles 6. Altered mental status

The nurse performs an assessment on a client newly diagnosed with rheumatoid arthritis. The nurse expects to note which early manifestations of the disease? (SATA) 1. Fatigue 2. Anorexia 3. Weakness 4. Low-grade fever 5. Joint deformities 6. Joint inflammation

1. Fatigue 2. Anorexia 3. Weakness 4. Low-grade fever 6. Joint inflammation

A client has glaucoma. The nurse reviews the client's medical record, expecting to note which of the following manifestations of this eye condition? (SATA) 1. Halos around lights 2. Headache or eye pain 3. Decreased visual acuity 4. Loss of peripheral vision 5. Increased accommodation 6. To nome try reading of 24mmHg

1. Halos around lights 2. Headache or eye pain 3. Decreased visual acuity 4. Loss of peripheral vision 6. To nome try reading of 24mmHg

A nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manifestation would alert the nurse to a hemolytic transfusion reaction? (SATA) 1. Headache 2. Tachycardia 3. Hypertension 4. Apprehension 5. Distended neck veins 6. A sense of impending doom

1. Headache 2. Tachycardia 3. Hypertension 4. Apprehension 6. A sense of impending doom

The nurse monitors a client who experienced a head injury. Which of the following are manifestations of an increase in intracranial pressure (ICP)? (SATA) 1. Headache 2. Tachycardia 3. Hypotension 4. Pupillary changes 5. Abnormal posturing 6. Widened pulse pressure

1. Headache 4. Pupillary changes 5. Abnormal posturing 6. Widened pulse pressure

A nurse is caring for a client with a diagnosis of retinal detachment. The client suddenly complains of a burst of black spots in the eye. The nurse interprets this symptom as indicating which of the following? 1. Hemorrhage as a result of the detachment 2. An expected finding 3. The need to restrict fluids 4. The need to patch the affected eye

1. Hemorrhage as a result of the detachment

Which of the following early findings would be noted in an infant who is positive for human immunodeficiency virus? 1. Hepatosplenomegaly 2. Sleepiness 3. Lethargy 4. Eye drainage

1. Heptosplenomegaly

A nurse assessing a female client with Cushing syndrome expects to note which of the following? 1. Hirsutism 2. Hypotension 3. Hypoglycemia 4. Pallor

1. Hirutism

The nurse provides information about the signs of hypoglycemia to a client with diabetes mellitus who is taking insulin. Which of the following signs should the nurse include in the information? (SATA) 1. Hunger 2. Sweating 3. Weakness 4. Nervous 5. Cool, clammy skin 6. Increased urinary output

1. Hunger 2. Sweating 3. Weakness 4. Nervous 5. Cool, clammy skin

A nurse is assigned to care for a client who is attached to a mechanical ventilator and is receiving propofol (Diprivan). The nurse plans to monitor the client closely for which adverse effect of the medication? 1. Hypotension 2. Facial flushing 3. Tachycardia 4. Increased respiratory rate

1. Hypotension

A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse that the IV site is swollen. The nurse assesses the IV site and notes that it is also cool and pale and that the IV has stopped running. The nurse documents that which of the following has probably occurred? 1. Infiltration 2. Phlebitis 3. Thrombosis 4. Infection

1. Infiltration

A nurse is collecting data from a client with the diagnosis of Brown-Sequard syndrome. Which of the following findings does the nurse expect to note? 1. Ipsilateral paralysis and los of touch and vibration sensation 2. Bilateral loss of pain and temperature sensation 3. Contralateral paralysis and loss of touch and vibration sensation 4. Complete paraplegia or quadriplegia, depending on the level of injury

1. Ipsilateral paralysis and loss of touch and vibration sensation

A client underwent creation of an ileostomy 2 days ago. The nurse assesses the client for signs of which acid-base disorder that can occur in a client with an ileostomy? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis

A nurse is reviewing the arterial blood gas (ABG) results of a client in the respiratory care unit and notes that pH is 7.38, PCO2 is 38 mm Hg, PO2 is 86 mm Hg, and HCO3 is 23 mEq/L. The nurse interprets that the client's blood gases indicate which of the following? 1. Normal results 2. Metabolic alkalosis 3. Metabolic acidosis 4. Respiratory acidosis

1. Normal results

The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How would the nurse correctly analyze these results? 1. Results are positive for active tuberculosis 2. Results indicate a less virulent strain of tuberculosis 3. Results are inconclusive until. Repeat sputum is sent 4. Results are unreliable unless the client has also had a positive Mantoux test

1. Results are positive for active tuberculosis

A client is diagnosed with Menière disease and asks the nurse to describe the disorder. The nurse provides the client with which information? (SATA) 1. Ringing in the ears occurs 2. It is characterized by vertigo 3. Bilateral sensorineural hearing loss occurs 4. Permanent hearing loss develops as the attacks increase 5. Cigarette smoking needs to be avoided because of the blood vessel - constricting effect 6. Salt and fluid restrictions that reduce the amount of fluid in the ear may be helpful

1. Ringing in the ears occurs 2. It is characterized by vertigo 4. Permanent hearing loss develops as the attacks increase 5. Cigarette smoking needs to be avoided because of the blood vessel - constricting effect 6. Salt and fluid restrictions that reduce the amount of fluid in the ear may be helpful

The nurse caring for a client receiving intravenous (IV) therapy should monitor for which signs of infiltration at the catheter site of an IV infusion? (SATA) 1. Slowing of the IV rate 2. Tenderness at the insertion site 3. Edema around the insertion site 4. Skin tightness at the insertion site 5. Warmth of skin at the insertion site 6. Fluid leaking from the insertion site

1. Slowing of the IV rate 2. Tenderness at the insertion site 3. Edema around the insertion site 4. Skin tightness at the insertion site 6. Fluid leaking from the insertion site

A nurse is assessing a pregnant client with a diagnosis of abruptio placental. The nurse expects to note which manifestations of this condition? (SATA) 1. Uterine irritability 2. Uterine tenderness 3. Bright red vaginal bleeding 4. Abdominal and low back pain 5. Strong and frequent contractions 6. Non-reassuring fetal heart rate patterns

1. Uterine irritability 2. Uterine tenderness 4. Abdominal and low back pain 6. Non-reassuring fetal heart rate patterns

A clinic nurse is assessing a client who had a total gastric to my 2 months ago. The nurse checks which of the following that would indicate a specific complication of this procedure? 1. Vitamin B12 and folic acid levels 2. Blood urea nitrogen 3. Pupillary response to light 4. Calcium levels

1. Vitamin B12 and folic acid levels

A nurse witnesses a client going into pulmonary edema. The client exhibits respiratory distress, but the blood pressure is stable at this time. While waiting for help to arrive, the nurse performs the following actions in which order of priority? 1. Rechecks the vital signs 2. Places the client in high-Fowler position 3. Calls the respiratory therapy department for a ventilator 4. Places the client on a pulse oximeter and cardiac monitor 5. Begins the client's oxygen at 2 liters by nasal cannula as needed (PRN) 6. Administers the client's morphine sulfate intravenous injection PRN

2, 5, 4, 1, 6, 3 Places the client in high-Fowler position Begins the client's oxygen at 2 liters by nasal cannula as needed (PRN) Places the client on a pulse oximeter and cardiac monitor Rechecks the vital signs Administers the client's morphine sulfate intravenous injection PRN Calls the respiratory therapy department for a ventilator

A physician prescribes a diltiazem hydrochloride (Cardizem) intravenous bonus followed by an intravenous infusion of the same medication to control a rapid atrial fibrillation. In preparing the medication, the nurse is aware of which of the following? 1. A diltiazem hydrochloride bonus must be pushed very rapidly over a period of 2 to 3 seconds 2. A diltiazem hydrochloride infusion should not infuse for more than 24 hours 3. Diltiazem hydrochloride is the only effective beta-blocker for treating dysrhythmias 4. Diltiazem hydrochloride increases myocardial contractility and thus increases oxygen demand

2. A diltiazem hydrochloride infusion should not infuse for more than 24 hours

The results of a nonstress stress test are documented in the chart as "no accelerations during a 40-minute observation." The nurse interprets these findings as which of the following? 1. A reactive nonstress test 2. A nonreactive nonstress test 3. Equivocal 4. Unsatisfactory

2. A nonreactive nonstress test

A client comes into the health care clinic stating that she thinks she has restless leg syndrome. The nurse assesses the client and determines that which data are characteristics of this disorder? (SATA) 1. A heavy feeling in the legs 2. Burning sensations in the limbs 3. Symptom relief when lying down 4. Decreased ability to move the legs 5. Symptoms that are worse in the morning 6. Feeling the need to move the limbs repeatedly

2. Burning sensations in the limbs 6. Feeling the need to move the limbs repeatedly

Following assessment and diagnostic evaluation, it has been determined that a client has stage II of Lyme disease. The nurse expects to note which assessment finding that is indicative of this stage? 1. Erythematous rash 2. Cardiac conduction defects 3. Arthralgias 4. Enlargement of joints

2. Cardiac conduction defects

A nurse is caring for a client admitted to the hospital with acute myocardial infarction (MI). The nurse should monitor the client for which most common complication of MI? 1. Cardiogenic shock 2. Cardiac dysrhythmias 3. Congestive heart failure 4. Recurrent myocardial infarction

2. Cardiac dysrhythmias

A nurse is monitoring a client diagnosed with a ruptured appendix for signs of peritonitis and assesses for which of the following? (SATA) 1. Bradycardia 2. Distended abdomen 3. Subnormal temperature 4. Rigid, boardlike abdomen 5. Diminished bowel sounds 6. Inability to pass flats or feces

2. Distended abdomen 4. Rigid, boardlike abdomen 5. Diminished bowel sounds 6. Inability to pass flats or feces

A nurse should review the laboratory results of a client with Cushing syndrome for which characteristic manifestations? 1. Hypokalemia 2. Hyperglycemia 3. Decreased plasma cortisol levels 4. Low white blood cell count

2. Hyperglycemia

A client with glomerulonephritis is at risk of developing acute renal failure. The nurse should monitor the client for which of the following signs of this complication? 1. Bradycardia 2. Hypertension 3. Decreased cardiac output 4. Decreased central venous pressure

2. Hypertension

A client is admitted to the emergency department with drug-induced anxiety related to over-ingestion of prescribed antipsychotic medication. The most important piece of information the nurse should obtain initially is the: 1. Name of the nearest relative and his or her phone number 2. Name of the ingested medication and the amount ingested 3. Cause of the attempt and if the client plans another attempt 4. Length of time on the medication and any noted side effects

2. Name of the ingested medication and the amount ingested

During history taking of a client admitted to the hospital with newly diagnosed early-stage Hodgkin disease, which of the following would the nurse expect the client to report? 1. Weight gain 2. Night sweats 3. Severe lymph node pain 4. Headache with minor visual changes

2. Night sweats

A nurse is assessing the neurological status of a client who had a craniotomy 3 days ago. The nurse should notify the surgeon immediately if the client exhibits which of the following signs or symptoms? 1. Pupils equal and reactive at 4mm in size 2. Pain with forward flexion of the neck onto the chest 3. Mild headache relieved by codeine sulfate 4. Disorientation to date

2. Pain with forward flexion of the neck onto the chest

The nurse develops a care plan for a client receiving hemodialysis who has an arteriovenous (AV) fistula in the right arm. The nurse includes which interventions in the plan to ensure protection of the AV fistula? (SATA) 1. Assess pulses and circulation proximal to the fistula 2. Palpate for thrills and auscultation for a bruit every 4 hours 3. Check for bleeding and infection at hemodialysis needle insertion sites 4. Avoid taking blood pressure or performing venipunctures in the extremity 5. Instruct the client not to carry heavy objects or anything that compresses the extremity 6. Instruct he client not to sleep in a position that places his or her body weight on top of the extremity

2. Palpate for thrills and auscultation for a bruit every 4 hours 3. Check for bleeding and infection at hemodialysis needle insertion sites 4. Avoid taking blood pressure or performing venipunctures in the extremity 5. Instruct the client not to carry heavy objects or anything that compresses the extremity 6. Instruct he client not to sleep in a position that places his or her body weight on top of the extremity

The nurse is assessing a client who has been hospitalized with acute pericarditis for signs of complications. The nurse monitors the client for which manifestation of cardiac tamponade? 1. Bradycardia 2. Paradoxical pulse 3. Flattened jugular veins 4. Bounding heart sounds

2. Paradoxical pulse

The nurse instructs a mother of a child who had a plaster cast applied to the arm about measures that will help the cast dry. Which instructions should the nurse provide to the mother? (SATA) 1. Lift the cast using the fingertips 2. Place the child on a firm mattress 3. Direct a fan toward the cast to facilitate drying 4. Support the cast and adjacent joints with pillows 5. Place the extremity with the cast in a dependent position 6. Reposition the extremity with the cast every 2 to 4 hours

2. Place the child on a firm mattress 3. Direct a fan toward the cast to facilitate drying 4. Support the cast and adjacent joints with pillows 6. Reposition the extremity with the cast every 2 to 4 hours

A nurse expects a client experiencing an acute myocardial infarction to first manifest which of the following patterns on the electrocardiography? 1. An abnormal Q wave 2. ST segment elevation 3. T wave elevation 4. Absent P waves

2. ST segment elevation

A nurse is assessing a client with a suspected diagnosis of acute pancreatitis. The nurse should check the client for which characteristic sign of this disorder? 1. Severe abdominal pain relieved by lying flat and still 2. Severe abdominal pain that is unrelieved by vomiting 3. Hypothermia 4. Epigastric pain radiating to the neck area

2. Severe abdominal pain that is unrelieved by vomiting

The nurse notes that a client's cardiac rhythm on the cardiac monitor shows a rate of 53 beats per minute and a regular rhythm. The nurse interprets that the client is experiencing which of the following? 1. Atrial fibrillation 2. Sinus bradycardia 3. Ventricular fibrillation (VFib) 4. Premature ventricular contractions (PVCs)

2. Sinus bradycardia

A client begins to experience a tonic-clinic seizure. The nurse should take which of the following actions? (SATA) 1. Restrain the client 2. Turn the client to the side 3. Maintain the client's airway 4. Place a padded tongue blade into the client's mouth 5. Loosen any restrictive clothing that the client is wearing 6. Protect the client from injury, and guide the client's movements

2. Turn the client to the side 3. Maintain the client's airway 5. Loosen any restrictive clothing that the client is wearing 6. Protect the client from injury, and guide the client's movements

An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. On assessment of the client, which finding would indicate that the client also sustained a respiratory injury as a result of the burn? 1. Clear breath sounds 2. Use of accessory muscles for breathing 3. Fear and anxiety 4. Complaints of pain

2. Use of accessory muscles for breathing

A nurse is caring for a client with hypertension receiving furosemide (Lasix) daily. Which of the following would indicate to the nurse that the client might be experiencing a side effect related to the medication? 1. A chloride level of 98 mEq/L 2. A sodium level of 135 mEq/L 3. A potassium level of 3.1 mEq/L 4. A blood urea nitrogen (BUN) level of 15 mg/dL

3. A potassium level of 3.1 mEq/L

In reviewing the record of a client, a nurse notes that the physician has documented the presence of Chvostek sign. Based on this documentation, which of the following would the nurse expect to note on assessment of the client? 1. Discoloration of the abdomen and periumbilical area is present 2. Carpal spasm is elicited by compressing the upper arm and causing ischemia to the nerves dismally 3. A spasm of the facial muscles is elicited by tapping the facial nerve in the region of the parotid gland 4. The epidermal skin layer can be rubbed off by slight friction

3. A spasm of the facial muscles is elicited by tapping the facial nerve in the region of the parotid gland

A nurse is caring for a client who recently had a jugular catheter inserted. After connecting new tubing at the insertion site, the client states, "I feel lightheaded, weak, and somewhat short of breath." Which of the following should the nurse suspect may be occurring? 1. Fluid overload 2. Pneumothorax 3. Air embolism 4. Septicemia

3. Air embolism

An infant crawling on the floor of the playroom suddenly begins to cough and make loud, high-pitched wheezing sounds when breathing. The nurse immediately considers which of the following? 1. Difficulty clearing the airway because of the developmental stage 2. Increased susceptibility for infection related to an immature immune function 3. Aspiration caused by the ingestion of a foreign object 4. Difficulty breathing related to inhalation of an allergen

3. Aspiration caused by the ingestion of a foreign object

A nurse reviews an electrocardiography rhythm strip and finds an irregular baseline with no identifiable P waves. Additionally, the QRS complexes are very irregular. The nurse analyzes this finding as which of the following? 1. Normal findings 2. Major ventricular dysrhythmia 3. Atrial fibrillation 4. A cause of increased cardiac output

3. Atrial fibrillation

A nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which of the following findings would the nurse expect to note on assessment of the client? 1. Complaints of diarrhea 2. Petechiae on the upper extremities 3. Chills and night sweats 4. High fever

3. Chills and night sweats

A client complains of pain in the mouth 10 days after receiving chemotherapy. Which of the following should the nurse address as a priority? 1. Inadequate nutritional intake 2. Presence of skin breakdown 3. Client complains of pain 4. Increased susceptibility for infection

3. Client complains of skin breakdown

A client enters the health care clinic after an episode of Raynaud phenomenon. The nurse should ask the client about a history of which of the following that may be associated with this disorder? 1. Microemboli as a result of atrial fibrillation 2. Chronic peripheral venous insufficiency 3. Collagen disorder such as lupus erythematosus 4. Lung disorders such as chronic airflow limitation

3. Collagen disorder such as lupus erythematosus

A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which of the following findings is an indication that complete uterine rupture may have occurred? 1. Excessive vaginal bleeding 2. Maternal bradycardia 3. Decreasing blood pressure 4. Increased uterine contractions

3. Decreasing blood pressure

The nurse is assessing the respiratory status of the client following thoracentesis. The nurse would become most concerned with which of the following assessment findings? 1. Equal bilateral chest expansion 2. Respiratory rate of 22 breaths per minute 3. Diminished breath sounds on the affected side 4. Few scattered wheezed, unchanged from baseline

3. Diminished breath sounds on the affected side

A client is experiencing acute cardiac and cerebral symptoms as a result of an excess fluid volume. The nurse should implement which of the following measures to increase the client's comfort until specific therapy is prescribed by the physician? 1. Measure urine output on an hourly basis 2. Measure intravenous and oral fluid intake 3. Elevate the client's head to at least 45 degrees 4. Administer oxygen at 4 liters per minute by nasal cannula

3. Elevate the client's head to at least 45 degrees

A clinic nurse is gathering data from a client and notes that the client is taking terazosin hydrochloride (Hytrin). Based on the action of this medication, the nurse asks the client about a history of which of the following disorders? 1. Cushing syndrome 2. Peptic ulcer disease 3. Hypertension 4. Esophagitis

3. Hypertension

A client being seen in the ambulatory care clinic has a history of being treated for syphilis infection. The nurse determines that the client has been reinfected if which of the following characteristics is noted in a penile lesion? 1. Popular areas and erythema 2. Cauliflower-like appearance 3. Induration and absence of pain 4. Multiple vesicles, with some that have ruptured

3. Induration and absence of pain

A nurse is developing a plan of care for a client placed in Buck extension traction after a hip fracture. The nurse determines that the priority consideration in caring for the client receiving this treatment is which of the following? 1. Lack of diversion all activity as a result of bed rest 2. Difficulty with bathing and other self-care measures because of the need for traction 3. Lack of mobility as a result of the traction device 4. Difficulty with social interactions because of the need for traction

3. Lack of mobility as a result of the traction device

A nurse is admitting a client with a diagnosis of Addison disease to the hospital. On assessment, the nurse expects to note which of the following findings that is a manifestation of this disorder? (SATA) 1. Peripheral edema 2. Excessive facial hair 3. Lower-than-normal blood glucose level 4. High blood pressure 5. Signs of dehydration

3. Lower-than-normal blood glucose level 5. Signs of dehydration

A nurse is developing a plan of care for a client who is experiencing a decrease in fluid volume after a burn injury. Which nursing intervention is appropriate to include in the plan? 1. Obtain and record weight every other day 2. Monitor intake and output (I&O) every shift 3. Monitor mental status every hour 4. Monitor vital signs every 4 hours

3. Monitor mental status every hour

A nurse is caring for a client with a history of mild heart failure who is receiving diltiazem hydrochloride (Cardizem) for hypertension. The nurse should assess the client for which of the following signs while the client is receiving this therapy? 1. Bradycardia 2. Wheezing 3. Peripheral edema and weight gain 4. Apical pulse rate lower than baseline

3. Peripheral edema and weight gain

A client is diagnosed with diabetes insipidus. The nurse performs an assessment on the client and expects to note which of the following? (SATA) 1. Bradycardia 2. Hypertension 3. Poor skin turgor 4. Increased urinary output 5. Dry mucous membranes 6. Decreased pulse pressure

3. Poor skin turgor 4. Increased urinary output 5. Dry mucous membranes 6. Decreased pulse pressure

A nurse is caring for a postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication? 1. Cold skin, drowsiness, and hypertension 2. Fever, irritability, and rapid respiration's 3. Tachycardia, cold skin, and hypotension 4. Slow pulse, warm skin, and respirations

3. Tachycardia, cold skin, and hypotension

A nurse should monitor a client after myocardial infarction for which signs that are indicative of cardiogenic shock? 1. Bradycardia, hypertension, and a pale appearance 2. Peripheral edema, distended neck veins, and hepatic engorgment 3. Tachycardia, confusion, and hypotension 4. Oliguria, bradypnea, and warm dry skin

3. Tachycardia, confusion, and hypotension

The nurse who is caring for a client with Graves' disease notes that the client has a problem with taking in adequate nutrition. The nurse develops a plan and should include which positive outcome for this problem? 1. The client verbalized the need to avoid snacking between meals 2. The client discusses the relationship between mealtime and the blood glucose level 3. The client maintains the normal weight or gradually gains weight if it is below normal level 4. The client demonstrates knowledge regarding the need to consume a diet high in fat and low in protein

3. The client maintains the normal weight or gradually gains weight if it is below normal level

The nurse witnesses an accident in which a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim and notes that the client is responsive and has suffered a flail chest involving at least three ribs. The nurse should do which of the following to assist the client's respiratory status until help arrives? 1. Remove the victim's shirt 2. Assist the victim to sit up 3. Turn the client onto the side with the flail chest 4. Apply firm but genial pressure with the hands to the flail segment

4. Apply firm but genial pressure with the hands to the flail segment

A nurse is developing a plan of care for a newborn infant with spina bifocals (meningomyelocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure (ICP). Which of the following assessment techniques should be performed to detect the presence of increased ICP? 1. Monitoring blood pressure for signs of hypotension 2. Monitoring for signs of dehydration 3. Monitoring urine for specific gravity 4. Assessing the anterior fontanelle for bulging

4. Assessing the anterior fontanelle for bulging

A nurse is assessing a client with hypertension being treated with diuretic therapy. The nurse monitors the client for hypokalemia if the client is receiving which of the following diuretics? 1. Triamterene (Dyrenium) 2. Amiloride hydrochloride (Midamor) 3. Spironolactone (Aldactone) 4. Bumetanide (Bumex)

4. Bumetanide (Bumex)

Quinidine gluconate is prescribed for a client. The nurse reviews the client's medical history for which condition that is a contraindication in the use of this medication? 1. Asthma 2. Infection 3. Muscle weakness 4. Complete atrioventricular block

4. Complete atrioventricular block

A client undergoing long-term peritoneal dialysis at home is currently experiencing a problem with reduced outflow from the dialysis catheter. The home care nurse should inquire whether the client has had a recent problem with which of the following? 1. Diarrhea 2. Vomiting 3. Flatulence 4. Constipation

4. Constipation

The "low exhaled volume" alarm sounds on a mechanical ventilator attached to a client with an endotracheal tube. The nurse anticipates that the cause of this alarm may be a result of which of the following? 1. Excessive secretions 2. The presence of a mucous plug 3. Kinks in the ventilator circuits 4. Displacement of the endotracheal tube

4. Displacement of the endotracheal tube

A client is suspected of having a pleural effusion. The nurse assesses the client for which typical manifestations of this respiratory problem? 1. Dyspnea and moist, productive cough 2. Dyspnea at rest and dry, nonproductive cough 3. Dyspnea on exertion and moist, productive cough 4. Dyspnea on exertion and dry, nonproductive cough

4. Dyspnea on exertion and dry, nonproductive cough

A nurse is performing an assessment on a male client with epididymitis. The nurse expects to note which of the following manifestations of this disorder? 1. Diarrhea, groin pain, and scrotal edema 2. Nausea and vomiting and scrotal edema with echo oasis 3. fever, diarrhea, groin pain, and ecchymosis 4. Fever, nausea and vomiting, and painful scrotal edema

4. Fever, nausea and vomiting, and painful scrotal edema

The nurse prepares to administer an intravenous (IV) medication when the nurse nots that the medication is incompatible with the IV solution. Which is the best intervention for the nurse to implement for safe medication administration? 1. Ask the provider to prescribe a compatible IV solution 2. Start a new IV catheter for the incompatible medication 3. Collaborate with the provider for a new administration route 4. Flush the tubing with normal saline before and after administering the medication

4. Flush the tubing with normal saline before and after administering the medication

A nurse is preparing to administer an inactivated poliovirus vaccine to a child. Which of the following assessment questions should the nurse ask the mother before administering? 1. Has the child had any diarrhea? 2. Has the child had any ear infections? 3. Has the child had any recent sore throats? 4. Has the child ever had an allergic reaction to neomycin?

4. Has the child ever had an allergic reaction to neomycin?

The nurse is collecting data from a client with benign prostatic hyperplasia. Which of the following is a late sign of disorder? 1. Nocturia 2. Decreased force of urine stream 3. Difficulty initiating urine stream 4. Hematuria

4. Hematuria

A nurse is assigned to care for a group of clients on the clinical nursing unit. The nurse determines that the client who is least likely to develop third spacing of fluids is the one with a diagnosis of which of the following: 1. Major burn 2. Renal failure 3. Laennec cirrhosis 4. Hypertension

4. Hypertension

A nurse is caring for a client with Parkinson's disease who is taking benztropine mesylate (cogent in) daily. The nurse assesses the client for side effects of this medication and specifically monitors which of the following? 1. Pupil response 2. Prothrombin time 3. Skin temperature 4. Intake and output

4. Intake and output

A client admitted to the hospital has chronic respiratory acidosis. The nurse anticipates that which of the following methods for administering oxygen to the client will be prescribed? 1. Partial rebreather mask 2. One hundred percent oxygen nonrebreather mask 3. High-flow 60% oxygen via face mask 4. Low-flow oxygen via nasal prongs at 2 L/min

4. Low-flow oxygen via nasal prongs at 2 L/min

A client undergoing hemodialysis has a newly created fistula in the left arm. The nurse monitors the affected extremity for which of the following signs and symptoms that indicate a complication related to steal syndrome? 1. Edema and purplish discoloration 2. Aching pain and edema 3. Warmth, redness, and pain 4. pallor, diminished pulse, and pain

4. Pallor, diminished pulse, and pain

A nurse is monitoring a client with abruptio placental for signs of disseminated intravascular coagulopathy (DIC). Which of the following signs would indicate the occupancy of DIC? 1. Pain and swelling of the calf of one leg 2. Rapid clotting lines 3. An increased platelet count 4. Petechiae, oozing from injection sites, and hematuria

4. Petechiae, oozing from injection sites, and hematuria

The nurse notes ventricular fibrillation on the client's cardiac monitor. The nurse hurries to the client's room, expecting the client to be: 1. Dizzy and nauseated 2. Complaining of severe palpitations 3. Hypotension and pale 4. Pulseless and unresponsive

4. Pulseless and unresponsive

Which of the following should the nurse assess for in a client who has pernicious anemia? 1. Constipation 2. Shortness of breath 3. Dusky lips and gums 4. Smooth, sore, and red tongue

4. Smooth, sore, and red tongue

A client is incubated and receiving mechanical ventilation. The physician has added 7 cm of positive end-expiratory pressure (PEEP) to the ventilator settings of the client. The nurse assesses for which of the following expected but adverse effects of PEEP? 1. Decreased peak pressure on ventilator 2. Increased temperature from 98°F to 100°F rectally 3. Decreased heart rate from 78 to 64 beats per minute 4. Systolic blood pressure decrease from 122 to 98 mm Hg

4. Systolic blood pressure decrease from 122 to 98 mm Hg

A nurse is performing an admission assessment on a newborn infant admitted to the nursery with the diagnosis of su Duran hematoma following a difficult vaginal delivery. The nurse should do which of the following to assess for major symptoms associated with subdural hematoma? 1. Monitors the urine for blood 2. Monitors the urinary output pattern 3. Tests for contracture of the extremities 4. Tests for equality of extremities when stimulating reflexes

4. Tests for equality of extremities when stimulating reflexes

A nurse is checking a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. The nurse interprets this observation as indicating which of the following? 1. The system is intact 2. A client's pneumothorax is resolving 3. The suction to the system is shut off 4. There is an air leak somewhere in the system

4. There is an air leak somewhere in the system

Excessive maternal blood loss and decreased renal perfusion are complications of placental abrupt ion. A nurse assesses for these complications by monitoring for which of the following signs? 1. Bounding pulses 2. Lethargy 3. Decreased respiration's 4. Urinary output less than 30 mL/hr

4. Urinary output less than 30 mL/hr

A nurse prepares to administer which of the following prescribed medications to a newborn within the first hour of life? (SATA) 1. Hepatitis B vaccine 2. Hepatitis A vaccine 3. Naloxone (Narcan) 4. Surfactant (Infasurf) 5. Erythromycin eye droops 6. Vitamin K (AquaMEPHYTON)

5. Erythromycin eye droops 6. Vitamin K (AquaMEPHYTON)