Exam 1: Adult Health

The unlicensed assistive personnel reports a client blood pressure of 90/60 mm Hg to the nurse.  The client's prescriptions say to notify the health care provider (HCP) if systolic blood pressure is <100 mm Hg.  What should the nurse do first?

The nurse is conducting an educational community outreach program on melanoma screening.  Which statement by a resident would indicate the need for further education?

The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block.  Which action should the nurse implement first?

When no changes are made to the diet or prescribed insulin, which client with type 1 diabetes mellitus does the nurse anticipate having the highest risk of developing hypoglycemia?

The nurse educates a group of clients in the infertility clinic about risk factors contributing to infertility.  Which factors should the nurse include in the teaching?  Select all that apply.

A client returns to the unit after receiving hemodialysis for the first time.  The client vomits once, reports headache, and appears restless and disoriented.  What is the priority intervention?

After six months of unprotected intercourse and failing to conceive, a 37-year-old female client reports feeling anxious and depressed because of her situation.  Which response by the nurse is most appropriate?

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them.  The nurse should assess the client with which rhythm first?

Based on the lung assessment information included in the hand-off report, which client should the nurse assess first?

A client underwent a transurethral resection of the prostate (TURP) today and has a 3-way Foley urinary catheter with continuous bladder irrigation (CBI).  The client reports lower abdominal pain rated as an 8 on a scale of 0-10.  What action should the nurse carry out first?

The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease process and home management.  Which statement by the client indicates comprehension of teaching?

The nurse is caring for a client admitted with incomplete fractures of right ribs 5-7.  The nurse notes shallow respirations, and the client reports deep pain on inspiration.  What is the priority at this time?

The nurse is teaching about the importance of dietary fiber at a community health fair.  Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan?  Select all that apply.

The nurse completes the preoperative assessment for a client scheduled for a total knee replacement today.  Which information should the nurse report to the health care provider (HCP) as soon as possible before the surgery?

A client receiving a first dose of IV cefazolin has developed a diffuse rash, hypotension, and shortness of breath.  Place the nurse's subsequent actions in the correct order.  All options must be used.

The clinic nurse is assessing a previously healthy 60-year-old client when the client says, "My hand has been shaking when I try to cut food.  I did some research online.  Could I have Parkinson's disease?"  Which response from the nurse is the most helpful?

The nurse cares for a client admitted with severe burns who is now on fluid resuscitation therapy.  Which assessment findings would best indicate that fluid resuscitation has been successful?

The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement.  Which finding requires priority action?

The telemetry nurse is reviewing a client's cardiac rhythm strip.  What is the correct interpretation for this strip?

The nurse is planning care for a client experiencing an acute attack of Meniere disease.  Which action is a high priority to include in the plan of care?