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1 A male client admitted with chronic pulmonary obstruction disease (COPD)
exacerbation is receiving assisted ventilation with continuous positive airway pressure
(CPAP). His vital signs are temperature 98.8 °F (37.1 °C), heart rate 118 beats/minute,
respirations 46 breaths/minute, blood pressure 176/92 mmHg. While completing the
pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to
arouse. Which action should the nurse implement?
a. Administer PAN nebulizer treatment.
b. Prepare for rapid sequence
intubation. c. Increase the
oxygen delivery by 10%.
d. Complete neurological assessment
2
An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his
foot. His daughter tells the nurse that her father has become increasingly obsessed
with the way his food is prepared in the hospital. The nurse's response should be
based on what information?
a. The family needs a social worker to talk to them about how to handle their father
when he becomes annoying.
b. The daughter is under stress and should be encouraged to think about happier
times.
c. If the client was compulsive about food when he was younger, the aging process
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can magnify this.
The client probably has an organic brain disease and will likely have Alzheimer's disease
within a few years
3 A young adult client is admitted to the emergency room following a motor vehicle
collision. The client's head hit the dashboard. Admission assessments include blood
pressure 85/45 mm Hg, oral temperature 98.6° F (37° C), pulse 124 beats/minute, and
respirations 22 breaths/minute. Based on these data, the nurse formulates the first
portion of a nursing problem as "Risk for injury". What term best expresses the
"related to" portion of the nursing problem?
a. head injury.
b. infection.
c. increased intracranial
pressure. d. shock.
4 Which client requires careful nursing assessment for signs and symptoms of
hypermagnesemia?
a. A client who developed hyperparathyroidism in late adolescence.
b. A female client who is overzealous with her intake of simple carbohydrates.
A middle-aged male client in renal failure following an unsuccessful
kidney transplant. d. A young adult client with intractable vomiting from
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food poisoning.
5 Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40
mmol/L SI). The nurse prepares to administer a unit of blood for an emergency
transfusion. The client has AB negative blood type and the blood bank sends a unit of
Type A Rh negative, reporting that there is no Type AB negative blood currently
available. Which intervention should the nurse implement?
a. Transfuse Type A negative blood until Type AB negative is available.
b. Recheck the clienfs hemoglobin, blood type, and Rh factor.
c. Obtain additional consent for administration of Type A negative blood.
d. Administer normal saline solution until Type AB negative is available.
6 An older client who lives alone in a two-story home is admitted after falling while
shopping. X-rays reveal a fractured left hip. With no immediate family in the area, the
client is concerned about the pets at home. Which interventions should the nurse
implement? (Select au that apply.)
A- Evaluate pain using a standard pain scale
B- Alert social worker of client's concerns.
C- Support left leg with two pillows.
D- Palpate and mark pedal pulses.
E- Assess ability to bear weight when standing
7 Which laboratory finding for an adult client is most critical for the nurse to report to
the healthcare provider? (Click on the correct location on the chart. To change, click on
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a new location.)
▪ Serum Sodio 142 mEq/L (142 mmol/L)
▪ Postassium 3.9 mEq/L (3.9 mmol'/L)
▪ Serum glucose 62 mg/dl (3.4 mmdl/L)
▪ Blood urea nitrogen 18 mg/dl (6.4 mmol/L)
8 An older adult client with heart failure (HF) develops cardiac tamponade. The client has
muffled, distant, heart sounds,
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