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A client with carcinoma of the lung is complaining of weakness and has a serum sodium
level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan
of care?
A. Altered urinary elimination
B. Impaired gas exchange
C. Fluid volume excess
D. Decreased cardiac output - ANSWERS-C. Fluid volume excess
A female client enters the clinic and insists on being seen. She is weak, nervous, and
reports a racing heart beat and recent weight loss of 15 pounds. After ruling out
substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her
for further testing. Which action should the nurse implement?
A. Begin preparing client for thyroidectomy procedure
B. Space the client's care to provide periods of rest
C. Assess the client for hyperactive bowel sounds
,D. Provide warm blankets to prevent heat loss - ANSWERS-B. Space the client's care
to provide periods of rest
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary
recommendations should the nurse encourage the client to follow?
A. Increase intake of high-fiber foods, such as bran cereal
B. Restrict protein intake by limiting meats and other high-protein foods
C. Limit oral fluid intake to 500 ml per day
D. Increase intake of potassium-rich foods such as bananas or cantaloupe -
ANSWERS-B. Restrict protein intake by limiting meats and other high-protein foods
An overweight, young adult made who was recently diagnosed with type 2 diabetes
mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak
and jittery. Which actions should the nurse implement? (Select all that apply.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
D. Document anxiety on the surgical checklist
E. Administer a PRN dose of regular insulin - ANSWERS-A. Check his fingerstick
glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure.
Which assessment finding warrants immediate intervention by the nurse?
A. Irregular apical pulse
B. Purple marks on the skin of the abdomen
C. Quarter size blood spot on dressing
,D. Pitting ankle edema - ANSWERS-A. Irregular apical pulse
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis
of her fingers. After warming her hands, the fingers turn red and the client reports a
burning sensation. What action should the nurse take?
A. Apply a cool compress to the affected fingers for 20 minutes
B. Secure a pulse oximeter to monitor the client's oxygen saturation
C. Report the finding to the healthcare provider as soon as possible
D. Continue to monitor the fingers until color returns to normal - ANSWERS-D. Continue
to monitor the fingers until color returns to normal
A male client with muscular dystrophy fell in his home and is admitted with a right hip
fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with
diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128
beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which
intervention is most important for the nurse to implement first?
A. Obtain oxygen saturation level
B. Encourage incentive spirometry
C. Assess lower extremity circulation
D. Administer PRN oral antipyretic - ANSWERS-D. Administer PRN oral antipyretic
The nurse is completing the preoperative assessment of a client who is scheduled for a
laparoscopic cholecystectomy under general anesthesia. Which finding warrants
notification of the healthcare provider prior to proceeding with the scheduled procedure?
A. Light yellow coloring of the client's skin and eyes
B. The client's blood pressure reading is 184/88 mm Hg.
C. The client vomits 20 ml of clear yellowish fluid
D. The IV insertion site is red, swollen, and leaking IV fluid - ANSWERS-B. The client's
blood pressure reading is 184/88 mm Hg
, A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediate action by the nurse?
A. Facial puffiness and periorbital edema
B. Hematocrit of 30%
C. Cold and dry skin
D. Further decline in level of consciousness - ANSWERS-D. Further decline in level of
consciousness
Following surgical repair of the bladder, a female client is being discharged from the
hospital to home with an indwelling urinary catheter. Which instruction is most important
for the nurse to provide to this client?
A. Avoid coiling the tubing and keep if free of kinks
B. Cleanse the perineal area with soap and water twice daily
C. Keep the drainage bag lower than the level of the bladder
D. Drink 1,000 ml of fluids daily to irrigate catheter - ANSWERS-C. Keep the drainage
bag lower than the level of the bladder
Which client has the highest risk for developing skin cancer?
A. A 16-year old dark-skinned female who tans in tanning beds once a week
B. A 65 year-old fair-skinned male who is a construction worker
C. A 25 year-old dark-skinned male whose mother had skin cancer
D. A 70 year-old fair-skinned female who works as a secretary - ANSWERS-B. A 65
year-old fair-skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most important
for the nurse to obtain?