Exam 1: Adult Health

A 64-year-old hospitalized client with chronic obstructive pulmonary disease exacerbation has increased lethargy and confusion.  The client's pulse oximetry is 88% on 2 liters of oxygen.  Arterial blood gas analysis shows a pH of 7.25, PO₂ of 60 mm Hg (8.0 kPa), and PCO₂ of 80 mm Hg (10.6 kPa).  Which of the following should the nurse implement first?

The camp nurse conducts a class for incoming summer counselors on prevention of tick bites and Lyme disease.  Which instructions should the nurse include?  Select all that apply.

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L).  The nurse should anticipate which findings?  Select all that apply.

The long-term care nurse is caring for a client diagnosed with macular degeneration.  Which client statement supports this diagnosis?

Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence?

The nurse is reinforcing teaching to a client with a hiatal hernia.  Which statement by the client indicates that further teaching is needed?

Which prescription should the nurse question when caring for a hospitalized client diagnosed with acute diverticulitis?

The nurse is providing discharge teaching for a client who suffered full-thickness burns.  Which statement by the client demonstrates a need for further instruction on the rehabilitation phase of a burn injury?

The nurse is reinforcing instructions to a client being discharged from the clinic with a diagnosis of acute prostatitis.  Which statement by the client indicates an understanding of the instructions?

A client who suffered a burn injury has received fluid resuscitation and is now diuresing, indicating the end of the emergency phase.  Which prescription is the highest priority at this time?

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone.  Which data should the nurse expect with the onset of this condition?  Select all that apply.

The nurse provides discharge teaching to a client who had a total knee replacement 4 days ago.  Which client statement indicates the need for additional teaching?

An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit.  Which assessment technique by the new nurse requires intervention by the RN?

The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure.  Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%.  Which of these findings supports the diagnosis of acute heart failure exacerbation?

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD).  The nurse anticipates which laboratory results for this client?

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA).  After checking the blood glucose, which prescription should the nurse implement first?

The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA).  The client's blood pressure today is 170/88 mm Hg.  What teaching topic is a priority for the nurse to discuss with this client?

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure.  Which is the best position for the nurse to place the client in when observing for JVD?

A nurse in an urgent care center triages multiple clients.  Which client should the nurse assess first?

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease.  Which of the following client statements indicate appropriate understanding of teaching?  Select all that apply.