Exam 1: Adult Health

The nurse cares for a client with type I diabetes mellitus.  Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy?

A client is admitted to the hospital for severe headaches.  The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid.  The client suddenly vomits and states, "That's weird, I didn't even feel nauseated."  Which action by the nurse is the mostappropriate?

The community health nurse provides an education program about risk factors for prostate cancer.  Which of the following statements by program attendees indicate that teaching has been effective?  Select all that apply.

The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago.  The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair.  Which action should the nurse implement first?

A clinic nurse is reviewing charts for clients who have appointments later in the day.  Which of the following clients should the nurse recognize as appropriate recipients of a prescription for emtricitabine/tenofovir?  Select all that apply.

The nurse receives report on 4 clients.  Which client should the nurse assess first?

A sexually active female client has had 3 urinary tract infections (UTIs) in 12 months.  Which instructions should the nurse include in teaching the client how to prevent UTI recurrence?  Select all that apply.

During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred.  The nurse stays with the client while another staff member gets sterile gauze and saline.  How should the nurse position the client while waiting to cover the wound?

A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min.  Which of the following actions should the nurse take?

The nurse is assisting with a colorectal cancer screening using the guaiac fecal occult blood test.  Place the steps for completing this test in the correct sequence.  All options must be used.

A client diagnosed with septic shock has an upward-trending glucose level (180-225 mg/dL [10.0-12.5 mmol/L]) requiring control with insulin.  The client's spouse asks why insulin is needed as the client is not a diabetic.  What is the most appropriate response by the nurse?

A nurse is caring for a client on the first day postop after having minimally invasive direct coronary artery bypass (MIDCAB) grafting.  The client thought that this surgery was supposed to have a much easier recovery and asks the nurse why it is so painful to take deep breaths.  What is the best response by the nurse?

During a routine clinic visit, the nurse is providing education to a 24-year-old female client with Marfan syndrome and aortic root dilation.  Which statement made by the nurse is appropriate?

Place the nursing actions for performing a renal system physical assessment in the correct order.  All options must be used.

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client.  Which rationale for indwelling urinary catheter insertion is most appropriate?

The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax.  Where would the nurse expect gentle, continuous bubbling?

A client is admitted to the hospital with an exacerbation of myasthenia gravis.  What are the appropriate nursing actions?  Select all that apply.

Nausea and vomiting in which client is of greatest concern to the nurse?

The public health nurse identifies which of the following clients as being at high risk for developing colorectal cancer?  Select all that apply.

A client taking morphine sulfate for acute pain has not voided in 6 hours.  The nurse suspects the client has developed urinary retention.  What is the priority nursing intervention?