Review Day

The nurse is caring for a client who has been diagnosed with atrial fibrillation. What is the most appropriate action when assessing the client’s vital signs?

• Assess the radial pulse for 30 seconds

• Assess the apical pulse for 60 seconds

• Assess the dorsalis pedis pulse for 60 seconds

• Assess the carotid pulse for 30 seconds

The nurse is caring for an adult client. When the client was admitted 2 days ago, the following were collected. HR 82bpm, RR 18/min, BP 142/84, SpO2 96% RA, T 98.9F Weight 72kg Height 67 inches. Today, the client reports feeling short of breath, and the nurse finds the following. HR 96bpm, RR 22/min, BP 152/88, SpO2 92% RA, T 98.5F Weight 74kg. For which of the following should the nurse assess?

• Fluid retention

• Hypertension

• Anxiety

• Bradypnea

During an assessment, the nurse notes the presence of nystagmus. For which of the following should the nurse assess? Select all that apply.

• Inner ear infection

• Cerebellar stroke

• Alcohol intoxication

• Glaucoma

Clients with increased fat around the middle of their body (central body fat) are at an increased risk for this:

• Gingivitis

• Myocardial infarction

• Stroke

• Cardiovascular disease

Older adults are at an increased risk for this because of their higher risk for falls.

• Stroke

• Traumatic Brain Injury

• Diabetes Mellitus

• Cataracts

The nurse is caring for a client who reports trouble breathing. Upon auscultation, the nurse hears crackles in the client’s lungs. What condition can contribute to pulmonary edema?

• Right sided heart failure

• Left sided heart failure

• An acute stroke

• Deep Vein Thrombosis (DVT)

When performing a cardiac assessment, the nurse notes the presence of a “whooshing” sound in the patient’s carotid artery. What is the priority concern for this client?

• Assessment of peripheral pulses

• Risk for bradypnea

• Risk for stroke

• Assessment of pain level

The nurse is caring for a client with vascular insufficiency of the lower extremities. The skin is pale, and there is no hair on the patient’s legs. Pedal pulses are non-palpable. The client is reporting pain. What is the nurse’s best action?

• Elevate the client’s legs.

• Place an ice pack on the client’s legs.

• Ambulate the client around the hospital unit 5 times.

• Place the client’s legs in a dependent position.

A client presents with the following signs: diffuse abdominal pain, and abdominal distention. What is the nurse’s next action?

• Auscultate the client’s bowel sounds

• Notify the physician that the client likely has appendicitis

• Administer 2mg of Morphine for the client’s pain as ordered

• Perform light palpation to determine the area of greatest pain

The nurse should be aware that which of the following are risk factors for a bowel obstruction? Select all that apply.

• Frequent ambulation

• Immobility

• Post-surgical status

• The use of narcotic pain medication