Exam 1: Adult Health

The family practice clinic nurse is conducting client intake histories.  Which client findings or histories indicate a need for heightened concern that the client may have cancer? Select all that apply.

The registered nurse (RN) is supervising a graduate nurse (GN) providing postoperative teaching for a male client after an inguinal hernia repair.  Which statement by the GN would cause the RN to intervene?

The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator.  What is the priority nursing diagnosis (ND)?

The nurse is planning care for a client being admitted with newly diagnosed quadriplegia (tetraplegia).  Which intervention will the nurse prioritize?

An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit.  The new RN is measuring orthostatic blood pressure (BP) for a client.  Which situation would warrant intervention by the experienced nurse?

The nurse is caring for a woman with obesity who is 3 days postoperative total hip joint replacement.  Which laboratory value is of greatest concern and should be reported to the health care provider (HCP) immediately?

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw.  The nurse understands that angina pectoris may be precipitated by which of these factors?  Select all that apply.

The nurse is caring for an assigned team of clients.  Which client is the priority for the nurse at this time?

The house supervisor has notified the charge nurse on the intensive care unit (ICU) that a bed is needed for an admission from the emergency department.  All ICU beds are currently full.  Which client should the charge nurse consider as most appropriate for transfer out of the ICU?

A 14-year-old is seen in the sexually transmitted disease (STD) outpatient department and diagnosed with gonorrhea.  The client tells the nurse of having sexual relations with only a 19-year-old partner.  What is the best response by the nurse?

An elderly client with osteoporosis falls onto an out-stretched hand and injures the wrist.  The client has severe wrist edema, deformity, and pain rated a 10 on a pain scale of 0-10.  What should be the nurse's first action?

The nurse provides post-procedure teaching for a female client who had a cystoscopy as an outpatient.  Which client statement indicates the need for additional instruction?

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area?

The nurse is preparing to administer 40 mg of IV furosemide.  Prior to administering the medication, the nurse should assess which parameters?  Select all that apply.

A critical care nurse is caring for a newly admitted client with acute aortic dissection.  Which prescription should the nurse prioritize while awaiting surgical revision of the client's aortic dissection?

A client sustained a concussion after falling off a ladder.  What are essential instructions for the nurse to provide when the client is discharged from the hospital?  Select all that apply.

A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed.  After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode.  The client is now pale and diaphoretic and reports dizziness.  Which action should the nurse perform first?

The nurse prepares to instill dialysate for a client receiving peritoneal dialysis.  Which nursing action is the priority?

A client presents to the emergency department with a stab wound to the chest.  The nurse assesses tachycardia, tachypnea, and a sucking sound coming from the wound.  Which of the following actions is priority?

A client is admitted with an exacerbation of asthma following a respiratory viral illness.  Which clinical manifestations characteristic of a severe asthma attack does the nurse expect to assess?  Select all that apply.