Exam 1: Adult Health

The nurse is caring for a client who has just returned from external fixation device placement for stabilization of a fractured femur.  Which of the following interventions are appropriate to include in the client's plan of care?  Select all that apply.

A client in the emergency department is admitted with a diagnosis of rule out myocardial infarction (MI).  Which laboratory test should the nurse monitor to determine if the client has had an MI?

A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye.  The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation.  What action is appropriate at this time?

The nurse has just completed discharge teaching for a client who had aortic valve replacement with a mechanical heart valve.  Which statement by the client indicates that teaching has been effective?

A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago.  The client is becoming increasingly restless.  He has been given intravenous morphine every 2 hours for severe pain.  Respirations are 28/min and shallow.  Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention?

A client comes to the emergency department after being assaulted.  Imaging studies show a simple fracture of the mandible.  The nurse assesses edema of the face and jaw, drooling, and bleeding in the mouth; the client rates pain as a 9 out of 10.  What is the priority nursing intervention?

The nurse reviews prescriptions for assigned adult clients.  Which prescription should the nurse question?

The nurse in the postanesthesia care unit (PACU) is caring for an unresponsive client who just came from the operating room following surgery under general anesthetic for colorectal cancer.  The nurse chooses what as the highest priority nursing diagnosis (ND)?

The nurse is teaching the home health client how to perform colostomy irrigation.  Which client action reveals that further teaching is required?

After receiving a change-of-shift report, the nurse should assess which client first?

A nurse working in a neurology clinic receives the following telephone messages.  Which client should the nurse call back first?

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods.  Which meal does the client choose to indicate that teaching has been effective?

A client with a hip fracture is placed in Buck traction.  Which activities are appropriate for the nurse to include in the client's plan of care?  Select all that apply.

When a client diagnosed with acute urinary retention is emergently catheterized, the nurse should initially assess for which priority manifestation that may occur as a result of the catheterization?

The nurse is caring for a client who, 30 minutes ago, underwent an ablation procedure for supraventricular tachycardia in the cardiac catheterization laboratory.  The client has a dressing over the femoral insertion site with a small amount of oozing blood.  Which action by the nurse causes the charge nurse to intervene?

The medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing.  The client becomes confused and restless, and respirations are 30/min.  What is the nurse's next action?

The health care provider prescribes clomiphene for 5 days, beginning on the fifth day of menses, for treatment of infertility.  After the nurse provides medication teaching, which client statement would indicate a need for further teaching?

The nurse is caring for a client with absence seizures.  The unlicensed assistive personnel (UAP) asks if the client will "shake and jerk" when having a seizure.  Which response from the nurse is the most helpful?

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis.  The client is receiving a heparin infusion and suddenly develops epistaxis.  Which laboratory value would indicate that the heparin infusion needs to be turned off?

The hospitalized client with anorexia nervosa is started on nutrition via enteral and parenteral routes.  Which client assessment is the most important for the nurse to check during the first 24-48 hours of administration?