Exam 1: Adult Health

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications.  While the nurse is preparing to administer the feeding, the tube becomes dislodged.  What is the most appropriate intervention?

A registered nurse is precepting a new graduate nurse on the orthopedic unit.  Which action by the graduate nurse requires the registered nurse to intervene?

Which of the following diets would place a client at the highestrisk for macrocytic anemia?

The client recently admitted to the assisted living center has impaired vision related to primary open-angle glaucoma.  Select the graphic that best illustrates the effects of glaucoma on the client's vision.

The nurse receives laboratory reports on 4 clients.  Which report is most concerning and should be reported to the health care provider?

A client with chronic obstructive pulmonary disease reports recent weight loss and poor appetite.  The client states that bloating, exhaustion, and shortness of breath make eating "not worth the effort."  Which statements by the nurse are appropriate to help improve the client's nutritional status?  Select all that apply.

The nurse is caring for a client who had a laparoscopic cholecystectomy 3 days ago.  The client's WBC count has increased from 11,200/mm³ (11.2 × 10⁹/L) to 14,600/mm³ (14.6 × 10⁹/L) over the last 24 hours.  The nurse understands that which of the following assessment findings indicate potential infection?  Select all that apply.

The clinic nurse is providing instructions to a client who will be wearing a Holter monitor for the next 24 hours.  Which instructions are important to review with the client?

The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to "reach the itch."  What is the nurse's priority action?

The nurse is caring for a client who had a large anterior wall myocardial infarction (MI) 24 hours ago.  Which finding is most important to report to the health care provider (HCP)?

The nurse is caring for a client with a history of tonic-clonic seizures.  After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes.  The client does not know the current location, does not know the current season, and has a headache.  The nurse documents the confusion and headache as which phase of the client's seizure activity?

The nurse is caring for a 78-year-old client with a urinary tract infection (UTI).  Which assessment finding would be most concerning and require immediate follow-up by the nurse?

The nurse is providing community health screening.  Which of the following clients should be referred to a health care provider for further evaluation?

A client with type 1 diabetes mellitus is on intensive insulin therapy.  The client is of the Islamic faith and insists on fasting during Ramadan.  What is the most important nursing action?

The nurse assesses a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago.  Which assessment technique should the nurse use to check for complications in this client?

The nurse is caring for a young adult who is considering becoming pregnant.  The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it."  How should the nurse respond?

A client suffering from bladder prolapse and subsequent stress urinary incontinence has discussed treatment options with the health care provider (HCP).  The nurse evaluates that the client understands support pessary use when the client makes which statement?

The nurse is teaching a group of clients diagnosed with diabetes mellitus.  Which lesson regarding foot care should be included?Select all that apply.

A nurse caring for a client with a central venous catheter (CVC) enters the client's room and notes that the CVC is dislodged and lying in the client's bed linens.  The client appears cyanotic and is tachypneic and diaphoretic.  Which of the following actions by the nurse are appropriate?  Select all that apply.

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress.  While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration.  What immediateaction does the RN take to correct the problem?