,### 1
A client who underwent cardiac stent placement four days ago
arrives to the
emergency department reporting a sudden onset of chest pressure
and shortness of breath. Which action should the nurse take next?
a. Listen for extra heart sounds,
murmurs, and r hythm with the bell of
the stethoscope.
b. Evaluate upper and lower extremities for perfusion,
pulse volume, and pitting edema.
c. Verify troponin level assessments are scheduled every 3-6 hours
for a series of three.
d. Obtain a 12-lead electrocardiogram and begin continuous
cardiac monitor- ing
Correct Answer: d. Obtain a 12-lead electrocardiogram and begin
continuous cardiac monitoring
### 2
While completing a health assessment for a client with migraine
headaches, the nurse assesses bilateral weakness in the clients
hand grips. The client reports joint pain and trouble twisting a
door knob due to weak- nesses. Which action should the nurses
take in response to these figures?
e. Implement fall precautions to reduce the clients risk of injury.
f. Explain that relief of the migraine pain will reduce related
, symptoms.
g. Gather additional assessment data about the pain and weakness.
h. Consult with the occupational therapist for a functional
assessment
Correct Answer: c. Gather additional assessment data about the
pain and weakness.
###3
The nurse is caring for a client diagnosed with psoriasis vulgaris
who is receiving psoralen and ultraviolet A light (PUVA)
treatment.
Which assessment finding indicates that the client has been
overexposed to the treatment?
i. Thick skin plaques topped by silvery white scales
j. Tenderness upon palpation and generalized erythema
k. Brown, rough, greasy, wart-like papules on the face
l. Requires sunglasses because sunlight hurts eyes
Correct Answer: b. Tenderness upon pal- pation and generalized
erythema
An adult client who had a gastric bypass surgery 2 weeks ago, is
admit- ted with possible anastomosis leakage. The client's
abdomen is tender to touch, and the vital signs are temperature
101* F (38 3* C). heart rate 130 beats/minute, Respiratory rate 26
breaths/minute, and blood pressure 100/50 mmHg.
###4
, Which intervention is most important for the nurse to include in the
client's plan of care?
m. Encourage regular turning.
n. Monitor skin for breakdown.
o. Strict IV fluid replacement
p. Assess wound drainage daily
Correct Answer: c. Strict IV fluid replacement
A client who was recently diagnosed with Raynaud's disease is
concerned about pain management.
Which nursing instructions should the nurse provide?
q. Painful areas should be rubbed gently until the pain subsides.
r. Return
appointments will be
needed for IV pain
medications.
s. Enrolling in a pain clinic can provide relief alternatives.
t. Wearing gloves when handling cold items guards against painful
spasms.-
Correct Answer: d. Wearing gloves when handling cold items guards
against painful spasms.
Client is recovering from a transurethral prostatectomy. Which
activity should be limited until after the first postoperative visit
with the healthcare provider?
A client who underwent cardiac stent placement four days ago
arrives to the
emergency department reporting a sudden onset of chest pressure
and shortness of breath. Which action should the nurse take next?
a. Listen for extra heart sounds,
murmurs, and r hythm with the bell of
the stethoscope.
b. Evaluate upper and lower extremities for perfusion,
pulse volume, and pitting edema.
c. Verify troponin level assessments are scheduled every 3-6 hours
for a series of three.
d. Obtain a 12-lead electrocardiogram and begin continuous
cardiac monitor- ing
Correct Answer: d. Obtain a 12-lead electrocardiogram and begin
continuous cardiac monitoring
### 2
While completing a health assessment for a client with migraine
headaches, the nurse assesses bilateral weakness in the clients
hand grips. The client reports joint pain and trouble twisting a
door knob due to weak- nesses. Which action should the nurses
take in response to these figures?
e. Implement fall precautions to reduce the clients risk of injury.
f. Explain that relief of the migraine pain will reduce related
, symptoms.
g. Gather additional assessment data about the pain and weakness.
h. Consult with the occupational therapist for a functional
assessment
Correct Answer: c. Gather additional assessment data about the
pain and weakness.
###3
The nurse is caring for a client diagnosed with psoriasis vulgaris
who is receiving psoralen and ultraviolet A light (PUVA)
treatment.
Which assessment finding indicates that the client has been
overexposed to the treatment?
i. Thick skin plaques topped by silvery white scales
j. Tenderness upon palpation and generalized erythema
k. Brown, rough, greasy, wart-like papules on the face
l. Requires sunglasses because sunlight hurts eyes
Correct Answer: b. Tenderness upon pal- pation and generalized
erythema
An adult client who had a gastric bypass surgery 2 weeks ago, is
admit- ted with possible anastomosis leakage. The client's
abdomen is tender to touch, and the vital signs are temperature
101* F (38 3* C). heart rate 130 beats/minute, Respiratory rate 26
breaths/minute, and blood pressure 100/50 mmHg.
###4
, Which intervention is most important for the nurse to include in the
client's plan of care?
m. Encourage regular turning.
n. Monitor skin for breakdown.
o. Strict IV fluid replacement
p. Assess wound drainage daily
Correct Answer: c. Strict IV fluid replacement
A client who was recently diagnosed with Raynaud's disease is
concerned about pain management.
Which nursing instructions should the nurse provide?
q. Painful areas should be rubbed gently until the pain subsides.
r. Return
appointments will be
needed for IV pain
medications.
s. Enrolling in a pain clinic can provide relief alternatives.
t. Wearing gloves when handling cold items guards against painful
spasms.-
Correct Answer: d. Wearing gloves when handling cold items guards
against painful spasms.
Client is recovering from a transurethral prostatectomy. Which
activity should be limited until after the first postoperative visit
with the healthcare provider?
