Description

Ans. A 6. After several days of coughing and taking acetaminophen to treat temperatures of 101 F (38. 3 C), a client with DI is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which intervention should the nurse implement first? a. Reassess vital signs b. Obtain sputum for culture c. Obtain a fingerstick glucose d. Administer an antipyretic Ans. A 7. A client takes daily supplemental iron tablets for iron deficiency anemia reports feeling increasingly fatigued. Which laboratory values should the nurse review? a. Serum electrolytes b. Complete blood count c. Liver enzymes d. Platelet count Ans. B 8. The nurse is caring for a client post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/ minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? a. Administer IV fluid bolus as prescribed by the healthcare provider b. Medicate for pain and monitor vital signs according to protocol c. Encourage the client to splint the incision with a pillow to cough and deep breathe d. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter Ans. B 9. A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fraction (ORIF). The nurse determines that the client’s distal pulses are diminished in the left foot. Which interventions should the nurse implement? (SATA) a. Offer ice chips and oral clear liquids b. Verify pedal pulses using a doppler pulse device c. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure d. Evaluate the application of the splint to the left leg e. Administer oral antispasmodics and narcotics analgesics Ans. B, C, D 10. A nurse is caring for a client with Diabetes Insipidus (DI). which data warrants the most immediate intervention by the nurse? a. Dry skin with inelastic turgor b. Apical rate of 110 beats per minute c. Polyuria and excessive thirst d. Serum sodium of 185 mEq/L Ans. D 11. The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? a. Platelet count b. Red blood cell count c. Hemoglobin levels d. White blood cell count Ans. A 12. A male client is admitted to the emergency department with vomiting of dark brown, foul- smelling emesis. He reports he had a surgical repair of a recurrent inguinal hernia one week ago and complains of intense abdominal pain. After assessing that his bowel sounds are hyperactive, which prescription should the nurse implement first? a. Place an indwelling urinary catheter and attach a bedside drainage unit b. Give a prescribed analgesic for temp above 101 F c. Insert a NGT and attach to low suction d. Send the patient to x-ray for a flat plate of the abdomen Ans. C 13. A client is admitted to the hospital for shortness of breath and chest pain after an episode of syncope. Which laboratory finding is most important for the nurse to report to the healthcare provider? a. Hematocrit Ans. D b. Blood glucose c. Oxygen saturation d. Troponin I 14. A client is hospitalized after experiencing a myocardial infarction (MI) to reduce cardiac workload, which intervention should the nurse include in the client’s plan of care? a. Teach to sleep in a side-lying position b. Encourage active range of motion exercises c. Provide a bedside commode for toileting d. Assist with ambulation in the hallway Ans. C 15. The healthcare provider prescribes radiation therapy (RT) for a client with terminal metastatic cancer who is experiencing increased pain due to spinal compression. The client asks the nurse why radiation therapy is prescribed. Which mechanism supports the use of RT in the client’s metastatic cancer? a. Implementation of all possible treatments offers clients the best chance of survival b. Pain relief can be provided by shrinking tumors that press against spinal nerves c. Evidence indicates that RT can prolong life in clients with metastatic cancers d. RT is an alternative to surgery that affects tumor growth and eradicates cancer Ans. B