Exam 1: Adult Health

A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy.  Which interventions are most important for the nurse to perform to prevent postoperative pneumonia?  Select all that apply.

The nurse cares for a client with ulcerative colitis who is having abdominal pain and ?10 bloody stools per day.  Which of the following interventions should be included in the client's plan of care?  Select all that apply.

The nurse is performing an initial assessment on a client diagnosed with Addison's disease.  Which assessment findings should the nurse anticipate?  Select all that apply.

The nurse is caring for a client after a lumbar puncture (spinal tap).  Which client assessment is most concerning and requires a nursing response?

A client diagnosed with head and neck cancer has developed mouth sores related to external radiation therapy.  The nurse teaches the client to use which of the following oral hygiene practices?  Select all that apply.

A self-employed auto mechanic is diagnosed with carbon monoxide poisoning.  Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air.  What is the nurse's priority action?

The nurse prepares to administer a dose of radioactive iodine (RAI) to a 39-year-old female client with Graves' disease.  Which action is most important for the nurse to take?

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery.  During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm.  What action should the nurse take?

The charge nurse is making rounds and should immediately intervene when making which observation?

The nurse is caring for a client following a transsphenoidal hypophysectomy.  Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus?  Select all that apply.

The nurse cares for a client with an exacerbation of inflammatory bowel disease (IBD).  The client tells the nurse about being infected with tuberculosis (TB) 10 years ago but never being medicated.  Which prescription is of concern and prompts the nurse to notify the health care provider (HCP)?

The clinic nurse is completing a health history for a client with suspected rheumatic fever (RF).  Which question is most important for the nurse to ask to establish a diagnosis?

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone fractures.  Which findings does the nurse expect to assess to support this diagnosis?  Select all that apply.

The nurse is giving report to a licensed practical nurse (LPN) who will be helping to monitor a client who just had a total thyroidectomy.  What will the nurse emphasize as most important to report immediately?

The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes.  Which cranial nerves is the nurse assessing?  Select all that apply.

The nurse assesses a client who had a thyroidectomy 8 hours ago.  The nurse finds the client anxious, with tingling around the mouth and muscle twitching in the right arm.  Which action is most important for the nurse to implement first?

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment.  Which actions should the nurse take to prepare the client for hemodialysis?  Select all that apply.

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes.  Status epilepticus is suspected.  Which nursing intervention should be performed first?

A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away.  How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal?

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis.  The client has oliguria, dark amber urine, and muscle pain.  The nurse should implement which prescription first?