| Graded A+
1. A patient with a history of glomerulonephritis presents with sudden weight
gain and decreased urine output. What should the nurse prioritize in their
assessment?
Evaluate the patient's dietary intake of protein.
Monitor the patient's blood pressure only.
Check for signs of infection in the patient's surgical site.
Assess for signs of fluid overload and electrolyte imbalances.
2. If a right-handed client presents with significant asymmetry in muscle
strength during a musculoskeletal assessment, what would be the most
appropriate nursing intervention?
Instruct the client to perform strength exercises.
Refer the client for further diagnostic evaluation.
Advise the client to rest and avoid physical activity.
Document the finding and schedule a follow-up in a month.
3. If a nurse finds that the client's vital signs indicate hypotension and
tachycardia after assessing a patient with bright red blood in vomit, what
should be the next step in management?
Order a CT scan of the abdomen.
Start administering oral fluids.
Initiate IV fluid resuscitation.
Schedule the patient for an endoscopy.
,4. Describe the significance of a butterfly rash in relation to systemic lupus
erythematosus.
The butterfly rash indicates an allergic reaction to medication.
The butterfly rash is a common symptom of eczema, showing
localized skin irritation.
The butterfly rash is a hallmark sign of systemic lupus
erythematosus, indicating potential systemic involvement.
The butterfly rash is a sign of a viral infection affecting the skin.
5. Discuss why increasing the intake of fruits and vegetables may lower cancer
risk.
Fruits and vegetables provide essential fats that are beneficial for
heart health.
Fruits and vegetables are primarily sources of protein that aid in
muscle repair.
Fruits and vegetables contain antioxidants and phytochemicals that
help protect cells from damage.
Fruits and vegetables are high in calories, which can help maintain
weight.
6. If a patient with COPD is admitted with an exacerbation, what immediate
nursing intervention should be prioritized?
Schedule a follow-up appointment with a pulmonologist.
Administer supplemental oxygen as needed to improve oxygen
saturation levels.
Provide education on smoking cessation only.
Encourage the patient to engage in physical therapy immediately.
,7. Why is it critical for the nurse to assess vital signs and consciousness in a
patient who has vomited bright red blood?
It is important to check for allergies before administering medication.
Assessing vital signs and consciousness helps determine the
severity of the condition and the need for immediate intervention.
This assessment is only necessary if the patient shows signs of shock.
The nurse should focus on obtaining a detailed history instead.
8. What is the optimal position for a client after bolus feeding through a
nasogastric tube?
Fowler's position
Lateral position
Supine position
Prone position
9. A client's serum calcium level is high. The nurse plans care knowing that which
hormones are directly responsible for maintaining the free or unbound
portion of the serum calcium within normal limits?
Adrenocorticotropic hormone
Parathyroid hormone
Follicle-stimulating hormone
Thyroid hormone
10. What is the primary purpose of applying heat to a contusion after 72 hours?
To reduce swelling and inflammation.
To promote blood flow and healing.
, To prevent infection in the injury.
To numb the pain in the affected area.
11. What is the recommended duration for a client to sustain an inhaled breath
during respiratory assessments?
10 seconds
5 seconds
3 seconds
2 seconds
12. When suctioning a client with a tracheostomy, an important safety measure
for the nurse is to:
Apply suction only as the catheter is being withdrawn.
Insert the catheter until the cough reflex is stimulated.
Hyperventilate the client with room air prior to suctioning.
Remove the inner cannula before inserting the suction catheter.
13. Describe the physiological effects of carbon monoxide on the body at a
level of 15% and how it might present in a patient.
Carbon monoxide binds to hemoglobin, reducing oxygen delivery,
which can cause symptoms like headache and dizziness.
Carbon monoxide increases oxygen delivery, leading to symptoms of
hyperoxia.
Carbon monoxide causes inflammation in the lungs, resulting in
coughing and wheezing.
Carbon monoxide has no significant effects at a level of 15%.