A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following adverse effects should the nurse
instruct the client to notify the provider? - ANSCalf pain
Numbness in the arms
Intense headache
A nurse is planning care for a client who is postoperative following a laparotomy and has a
closed-suction drain. Which of the following actions should the nurse take to manage the drain?
- ANSCompress the drain reservoir after emptying.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to the
nurse that the client's condition is improving? - ANSGlucose 272 mg/dL
A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The
nurse should identify which of the following findings as an indication of a myocardial infarction
(MI)? - ANSTroponin I 8 ng/mL
A nurse is planning a health promotional presentation for a group of African American clients at
a community center. Which of the following disorders presents the greatest risk to this group of
clients? - ANShypertension
A nurse is providing education to a client who is at risk for osteoporosis. Which of the following
instructions should the nurse include? - ANSWalk for 30 min four times per week.
A nurse is caring for a client who has an arterial line. Which of the following actions should the
nurse take? - ANSPlace a pressure bag around the flush solution.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the
following results should the nurse expect? - ANSPaCO2 56
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which
of the following instructions should the nurse include? - ANSFlex the foot every hour when
awake.
A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which
of the following actions should the nurse identify as the priority? - ANSPlace a tracheostomy
tray at the bedside.
A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse
should identify the need to revise the plan for which of the following clients? - ANSA client who
,is postoperative following abdominal surgery and reports feeling that something "popped" when
they coughed
A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The
nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions
should the nurse take? - ANSDocument that depolarization has occurred.
A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of
the following information should the nurse include in the instructions? - ANSSputum specimens
are necessary every 2 to 4 weeks until there are three negative cultures.
A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless,
dyspneic, and has crackles noted to the lung bases. Which of the following actions should the
nurse anticipate taking? - ANSSlow the infusion rate
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the
following findings is the nurse's priority? - ANSTemperature 38.9° C (102° F)
A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To
reduce the risk of falls when ambulating, the nurse should provide which of the following
instructions to the client? - ANSScan the environment by turning your head from side to side.
A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The
client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate
16/min, and temperature 36° C (96.80 F). Which of the following vital sign changes should alert
the nurse that the client might be hemorrhaging? - ANSHeart rate 110/min
A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The
client is unable to void on the bedpan. Which of the following actions should the nurse take first?
- ANSScan the bladder with a portable ultrasound.
A nurse is assessing a client who has advanced lung cancer and is receiving palliative care.
The client has just undergone thoracentesis. The nurse should expect a reduction in which of
the following common manifestations of advanced cancer? - ANSDyspnea
A nurse is caring for a client who is postoperative. - ANSNurses' Notes
Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2 on a scale
of 0 to 10. Client appears restless and frequently asks for water. Bilateral lower extremities cool
with +1 pedal pulses. Urine output is 40 mL for the past 2 hr. Moderate amount of bright red
drainage noted on surgical incision dressing.
Vital Signs
Temperature 37.6° C (99.7° F)
Heart rate 114/min
, Respiratory rate 22/min
Blood pressure 88/54 mm Hg
Oxygen saturation 93% on room air
Diagnostic Results
Hgb 18 g/dL (12 to 16 g/dL)
Hct 54% (37% to 47 %)
Total WBC count 11,000/mm3 (5,000 to 10,000/mm3)
Troponin T 0.04 ng/mL (less than 0.1 ng/mL)
Medical History.
History of hypertension. Acute myocardial infarction 1 year ago.
Complete the diagram by dragging from the choices below to specify what condition the client is
most likely experiencing, two actions the nurse should take to address that condition, and two
parameters the nurse should monitor to assess the client's progress. - ANSThe nurse should
insert a large-gauge IV and initiate a fluid challenge because the client is most likely
experiencing hypovolemia as evidenced by the client's restlessness, tachycardia, hypotension,
decreased pulses, cool extremities, and decreased urine output. The nurse should monitor the
client's urine output and blood pressure to evaluate the effectiveness of treatment.
A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the
greater trochanter of his left hip. Which of the following instructions should the nurse include in
the teaching? - ANSChange position every hour
A nurse is performing a preoperative assessment for a client. The nurse should identify that an
allergy to which of the following foods can indicate a latex allergy? - ANSavocados
- ANSVital Signs
Blood pressure 155/98 mm Hg
Heart rate 98/min
Respiratory rate 14/min
Temperature 38.4° C (101.1 ° F)
Medication Administration Record
Gentamicin 60 mg intermittent IV bolus Q8H
Ceftriaxone 1 g intermittent IV bolus BID
Morphine 2.5 mg IV bolus Q3H PRN for pain
Acetaminophen 650 mg PO Q6H PRN for fever greater than 38°C (100.4° F)
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