Exam 1: Adult Health

The nurse is caring for a client in the postanesthesia care unit following a gastroduodenostomy.  Which of the following nursing interventions are appropriate?  Select all that apply.

A client has chronic obstructive pulmonary disease (COPD) exacerbation.  The pulse oximeter shows a saturation of 86% on room air.  The nurse assesses diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles.  What is the most appropriate oxygen delivery device for this client?

The clinic nurse provides teaching for a client scheduled for a barium enema the next day.  Which statement by the client shows a need for further instruction?

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day.  Which instructions should the nurse give the clients?  Select all that apply.

The nurse provides instruction to a community group about lung cancer prevention, health promotion, and smoking cessation.  Which statement made by a member of the group indicates the need for further instruction?

The home care nurse visits the house of an elderly client.  Which assessment finding requires immediate intervention?

The nurse assesses a client 5 minutes after initiating a blood transfusion.  The client has shortness of breath, itching, and chills.  The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub.  What action should the nurse take next?

Which instructions should the nurse include when providing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply.

A client with end-stage liver disease is admitted for a transplant workup.  The client's spouse states that the client has not stopped drinking alcohol and may be unable to quit for 6 months before the transplant.  Which is the most appropriate action for the nurse to implement?

The nurse is reviewing the history of four female clients.  The nurse should recommend a Pap test to screen for cervical cancer in which client?

A 78-year-old client recovering from a hip fracture tells the home health nurse, "I haven't had much of an appetite lately and have been really tired.  I'm worried I'm not eating enough."  Which question is the priority for the nurse to ask?

The nurse is caring for a 72-year-old client 1 day postoperative colectomy.  The nurse assesses an increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles, respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen.  There is no jugular venous distension or peripheral edema.  Pain is regulated with client-controlled morphine.  Which prescription does the nurse anticipate?

A graduate nurse (GN) is caring for a client with acute appendicitis who is awaiting surgery.  Which action by the GN would require the precepting nurse to intervene?

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension.  What clinical manifestations are most likely to be assessed?  Select all that apply.

The nurse is caring for a 50-year-old client in the clinic.  The client's annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago.  What should be the nurse's initial action?

The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department.  Which hospital protocol would be the most appropriate to follow initially?

An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3 hours.  Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion?

The nurse is planning care for a client with suspected stroke who has just arrived at the emergency department with slurred speech, facial drooping, and right arm weakness that began 1 hour ago.  Which of the following interventions should the nurse anticipate including in the initial plan of care?  Select all that apply.

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites.  Which assessment finding indicates that the albumin has been effective?

The nurse is caring for a client with cirrhosis of the liver.  Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results?  Select all that apply.