Exam 1: Adult Health

A nurse is evaluating an acutely ill client with suspected meningitis.  The nurse should take what action first?

The nurse is caring for a 72-year-old client with a history of renal calculi and diabetes mellitus who was admitted for acute pyelonephritis.  The nurse assesses shaking chills, temperature of 101.2 F (38.4 C), and flank pain.  Which of the following is the priority nursing intervention?

A client's diabetes is controlled with a morning dose of glargine and a scheduled, fixed dose of lispro with meals.  Before breakfast, the client's fingerstick glucose is 105 mg/dL (5.8 mmol/L).  The tray is in the room, and the client is eager to eat.  What action should the nurse take?

The nurse cares for a group of clients on a medical surgical floor.  The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)?

The health care provider suspects a rotator cuff injury in a client who is an avid tennis player.  The nurse would most likely assess which of the following?

The clinic nurse educator is developing a teaching plan for the following 6 clients.  The nurse should instruct which client to avoid the Valsalva maneuver when defecating?  Select all that apply.

The nurse is caring for a client with acute pancreatitis admitted 2 days ago.  Which assessment finding is most concerning?

The nurse has just administered a dose of 0.5 mg atropine to a client with a heart rate of 48/min and blood pressure of 90/62 mmHg.  Which rhythm strip would indicate that the medication achieved the desired outcome?

The nurse is evaluating how well a client with chronic obstructive pulmonary disease understands the discharge teaching.  Which statements made by the client indicate an understanding of the pursed-lip breathing technique?  Select all that apply.

The nurse is caring for a client with advanced heart failure on an inpatient hospice unit.  The client is having trouble breathing.  Which comfort intervention should the nurse implement first?

The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR.  The nurse receives and attaches an automated external defibrillator, but no shock is advised.  Which action should the nurse perform next?

The nurse takes the admission history of a 70-year-old client diagnosed with chronic obstructive pulmonary disease (COPD).  Which of the following statements by the client does the nurse recognize as contributing to the development of COPD?  Select all that apply.

When caring for a client with severe burns, the nurse can expect to administer pain medication via which route?

The graduate nurse cares for several poststroke clients.  Which of the following nursing interventions are appropriate?  Select all that apply.

An elderly client has a 17-mm induration after a tuberculin skin test (TST).  Based on this result, which statement is most accurate?

A clinic nurse receives messages on 4 clients.  Which client should the nurse call back first?

A client comes to the emergency department with crushing, substernal chest pain.  Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min.  Oxygen saturation is 95% on room air.  What is the nurse's next priority action?

The nurse has just completed discharge teaching for a client recently diagnosed with hypertension.  Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet?  Select all that apply.

The nurse is caring for a client with cirrhosis.  Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort.  Which interventions would be appropriate for the nurse to implement to promote the client's comfort?  Select all that apply.

The nurse is reviewing new prescriptions from the health care provider.  Which prescription would require further clarification?