Exam 1: Adult Health

The nurse receives hand-off report on assigned clients.  Which client should the nurse assess first?

The nurse assesses a client with a history of cystic fibrosis who is being admitted due to a pulmonary exacerbation.  Which assessment finding requires immediate action by the nurse?

The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices.  Which statement by the client indicates that the teaching was effective?

The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer.  The client is concerned because the health care provider said there was damage to the ninth cranial nerve.  Which statement made by the nurse is most appropriate?

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg.  The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg.  Which action by the nurse is most appropriate?

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort.  The nurse assesses the client's abdomen by pressing one hand firmly into the abdominal wall.  The client experiences pain when the nurse quickly withdraws the hand.  The client's most recent blood glucose level is 210 mg/dL (11.65 mmol/L).  What is the priority action by the nurse?

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused.  The client is scheduled for discharge later today.  Which interventions are appropriate for the nurse to implement?  Select all that apply.

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury.  Which assessment finding is consistent with injury to the occipital lobe?

A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection.  Which nursing intervention is the priority in caring for this client?

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic.  Which statement by the nurse will best address these results?

A parent calls the nursing triage line during the evening.  The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do.  Which is the most important instruction to give the parent?

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination?  Select all that apply.

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke.  Which nursing diagnosis is the most appropriate for this client?

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis.  The health care provider prescribes a continuous IV infusion of nitroprusside sodium.  Which of these is the priority goal in initial management of hypertensive crisis?

A nurse in the emergency department cares for 4 clients with orthopedic injuries.  Which client should the nurse assess first?

A client comes to the emergency department in acute decompensated heart failure.  The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum.  After placing the client on oxygen via nasal cannula, which of these actions is the next priority?

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy.  Which statement by the client requires the most immediate action by the nurse?

The nurse is planning discharge teaching for a client who just received a permanent pacemaker.  Which topics should the nurse include?  Select all that apply.

When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first?

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy.  Which of the following interventions are appropriate?  Select all that apply.