Exam 1: Adult Health

A client is diagnosed with diabetic ketoacidosis (DKA).  The client reports frequent urination, thirst, and weakness.  The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes.  What is the priority nursing diagnosis (ND) at this time?

The nurse is assigned to care for a client who had a total hip replacement an hour ago.  Which of the following should the nurse assess first?

The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure.  Which of the following is the nurse's priority when caring for a client with a new tracheostomy?

The nurse assesses a client who is 2 days postoperative breast reconstruction surgery.  The client has 2 closed-suction Jackson Pratt bulb drains in place.  There is approximately 10 mL of serosanguineous fluid in each one.  One hour later, the nurse notices the bulbs are full of bright red drainage and measures a total output of 200 mL.  What is the nurse's priority action?

A client who was discharged following a prostatectomy performed 6 days ago calls the clinic and reports passing some small blood clots and experiencing a decreased urinary stream.  What is the nurse's best response?

What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) of 24 mm Hg?  Select all that apply.

A client with advanced osteoarthritis is admitted for right total knee arthroplasty.  Which characteristic manifestations does the nurse expect to assess in this client?  Select all that apply.

A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking.  Which of the following instructions by the nurse would be most appropriate at this time?

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L).  Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing?

The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG).  Which teaching is correct?  Select all that apply.

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera.  Which actions will the nurse include in the teaching plan?  Select all that apply.

The nurse is caring for a client with right upper quadrant pain and jaundice.  The client's alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values.  What questions would be most helpful regarding the etiology for these findings?  Select all that apply.

A client is admitted with a pulmonary embolus.  The nurse assesses restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety.  Arterial blood gases indicate respiratory alkalosis and hypoxemia.  When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority?

A client was medicated with intravenous morphine 2 mg 2 hours ago to relieve moderate abdominal pain after appendectomy.  The client becomes lethargic but arouses easily to verbal and tactile stimuli, and is oriented to time, place, and person.  The pulse oximeter reading has dropped from 99% to 89% on room air.  Which oxygen delivery device is the most appropriate for the nurse to apply?

Which health history information would be most important for the nurse to obtain when assessing a client with suspected bladder cancer who reports painless hematuria?

A nurse cares for a frail, elderly client with osteoporosis in a nursing home.  Which interventions are appropriate to include in the client's care plan to help prevent a hip fracture?  Select all that apply.

The nurse receives the handoff of care report on four clients.  Which client should the nurse see first?

The nurse admits a client who fell off a 20-ft (6-m) ladder.  On arrival in the emergency department, the client is arousable but lethargic.  What is the nurse's priority action?

A client is brought to the emergency department due to loss of consciousness after binge drinking at a college party and then taking alprazolam.  Pulse oximetry shows 87% on room air.  Which findings would the nurse expect to assess on an arterial blood gas?

A clinic nurse examines a client with a tentative diagnosis of primary Sjögren's syndrome.  Which finding observed by the nurse would most likely be associated with this syndrome?