Exam 1: Adult Health

The nurse is caring for a 68-year-old male client following a laparoscopic cholecystectomy 8 hours ago.  The client has not urinated since surgery.  Which would be the most appropriate initial intervention?

A client is being discharged after receiving an implantable cardioverter defibrillator.  Which statement by the client indicates that teaching has been effective?

The nurse is preparing to discharge a client who is stable following a head injury.  Which statement by the client indicates a need for further discharge instructions?

The nurse in the endocrinology clinic is reviewing phone messages from clients.  Which client would be the priority to call first?

The nurse is teaching about cervical cancer prevention during a women's health conference.  Which of the following factors should be taught as risks for cervical cancer?  Select all that apply.

The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, "I can't breathe."  The client seems to be having difficulty breathing and is nervous and tremulous.  Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally.  Which intervention would be most appropriate at this time?

A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm.  Which finding should the nurse report immediately to the health care provider?

A client comes to the emergency department with diplopia and recent onset of nausea.  Which statement by the client would indicate to the nurse that this is an emergency?

The nurse in the intensive care unit cares for a client with primary adrenocortical insufficiency (Addison's disease).  The client reports nausea and abdominal pain.  The blood pressure suddenly drops from 120/74 mm Hg to 88/48 mm Hg, heart rate increases from 80 to 100/min, and the client appears confused.  Which action should the nurse take first?

A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside.  Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded.  Which is the priority nursing action?

The nurse is planning care for a client immediately following a thyroidectomy.  Which of the following nursing actions are appropriate to include in the plan of care?  Select all that apply.

The nurse is caring for a client who is 12 hours postoperative total hip replacement.  Which nursing intervention is appropriate to help prevent dislocation of the hip prosthesis?

The nurse is caring for an adolescent newly diagnosed with a chlamydial infection.  After administering a one-time dose of azithromycin, the nurse understands that which of the following client statements indicate a correct understanding of client teaching?  Select all that apply.

The nurse is caring for a client with an ileal conduit.  While assisting the client in removing the external pouch, the nurse observes that the stoma appears bluish grey.  What is the nurse's best action?

The health care provider (HCP) orders a small bowel follow-through (SBFT) for a client.  Which instructions should the nurse include when teaching the client about this test?

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, "I guess I can anticipate getting this disease myself at some point."  What is an appropriate response by the nurse?

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago.  The client's nail beds appear dusky.  What are the nurse's appropriate actions?  Select all that apply.

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider?

The nurse provides discharge instructions to a client one day after laparoscopic cholecystectomy.  Which statement by the client indicates that further teaching is required?

The nurse is assigned to the following clients.  Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)?