Exam 1: Adult Health

The nurse is caring for a client with multiple renal calculi.  Which nursing interventions should be included in the plan of care?  Select all that apply.

A client is diagnosed with right-sided Bell's palsy.  What instructions should the nurse give this client for care at home?  Select all that apply.

The client has a chest tube for a pneumothorax.  While repositioning the client for an x-ray, the technician steps on the tubing and accidently pulls the chest tube out.  The client's oxygen saturation drops and the pulse is 132/min; the nurse hears air leaking from the insertion site.  What is the nurse's immediate action?

The nurse is assessing a group of clients in the community health clinic for metabolic syndrome.  Which clients exhibit features of the syndrome?  Select all that apply.

Thrombotic thrombocytopenic purpura is suspected due to the client's current platelet count of 2,000/mm³ (2 x 10⁹/L).  Which client sign or symptom is the most concerning and requires immediate further nursing action?

The nurse is caring for a client with suspected Graves disease.  Which assessment finding requires priority intervention?

A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehabilitation via oral and enteral feedings.  Which of the following findings would indicate that the client is developing refeeding syndrome?

The nurse is conducting a health-screening clinic at an industrial work site.  The nurse should be most concerned about which client's risk for metabolic syndrome?

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago.  Which assessment findings would indicate possible graft leakage and require a report to the primary care provider?  Select all that apply.

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

A client who underwent open reduction and internal fixation of a right tibial fracture 10 hours ago reports worsening leg pain that is unrelieved by PRN morphine.  The nurse assesses that the client's right foot is cooler than the left.  What is the nurse's priority action?

During a screening clinic, the nurse performs a health assessment on several adult clients.  Which finding by the nurse is most important to report to the primary health care provider?

A client is scheduled for a coronary arteriogram procedure.  Which information should the nurse provide to the client prior to the procedure?  Select all that apply.

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg.  Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy?  Select all that apply.

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP).  Which assessment data is most important for the nurse to report to the HCP?

The emergency department nurse cares for 5 clients.  Which of the clients below are at risk for developing metabolic acidosis?  Select all that apply.

A nurse is teaching home management to a client newly diagnosed with severe psoriasis.  Which client statement indicates that further teaching is needed?

The nurse teaches disease management to a group of clients with type I diabetes mellitus.  Which of the following should the nurse teach as signs or symptoms associated with hypoglycemia?  Select all that apply.

The clinic nurse reinforces teaching to a client with systemic lupus erythematosus.  Which instructions will the nurse include?  Select all that apply.

A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical-surgical unit.  The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse.  Which action by the nurse is appropriate?