A 70-year-old female client with type 2 diabetes mellitus comes to the emergency department with diaphoresis, nausea, generalized weakness, and epigastric burning pain.  Which intervention should the nurse implement first?

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis.  Which of the following clinical manifestations should the nurse expect?  Select all that apply.

A client comes to the emergency department in acute decompensated heart failure.  The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum.  After placing the client on oxygen via nasal cannula, which of these actions is the next priority?

A clinic nurse is caring for a client who has hypertension and is prescribed hydrochlorothiazide, lisinopril, and clonidine.  The current blood pressure reading is 190/102 mm Hg, and the client reports a headache that has lasted several days.  Which question is most important for the nurse to ask next?

A client diagnosed with heart failure has an 8-hour urine output of 200 mL.  What is the nurse's first action?

A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min.  Which of the following actions should the nurse take?

A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema caused by his congestive heart failure.  Which of the following statements indicates that further teaching is required?

The nurse is performing an initial assessment on a client in hypertensive crisis.  What is the nurse's priority assessment?  Click on the exhibit button for additionalinformation. Vital signs BP 210/120 mm Hg HR 109/min R 20/minO₂  O2 96%

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 admitting a client with a diagnosis of Left-sided heart failure resulting from pulmonary hypertension. 

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency?

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 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 office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow.  Which statement made by the client indicates an understanding of the nurse's teaching?

The nurse reviews discharge instructions with a client who has advanced chronic obstructive pulmonary disease.  Which client statement indicates appropriate understanding?  Select all that apply.

A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full face mask with continuous positive airway pressure (CPAP).  Oxygen saturation drops to 85% during the night.  What is the nurse's first action?

A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep.  The client can feel thick mucus in the chest and throat.  Which interventions can the nurse suggest to help mobilize secretions and improve sleep?  Select all that apply.

A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago.  Which intervention should the nurse implement first?

A client with chronic obstructive pulmonary disease reports recent weight loss and poor appetite.  The client states that bloating, exhaustion, and shortness of breath make eating "not worth the effort."  Which statements by the nurse are appropriate to help improve the client's nutritional status?  Select all that apply.

The nurse is assessing a client an hour after a left lung lobectomy.  The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale.  Pulse oximetry is 92% on 4 L oxygen via nasal cannula.  The chest tube is set to continuous water seal suction at -20 cm H₂O.  The collection chamber has accumulated 320 mL of frank red drainage in the last hour.  What is the priority nursing action?

A 64-year-old hospitalized client with chronic obstructive pulmonary disease exacerbation has increased lethargy and confusion.  The client's pulse oximetry is 88% on 2 liters of oxygen.  Arterial blood gas analysis shows a pH of 7.25, PO₂ of 60 mm Hg (8.0 kPa), and PCO₂ of 80 mm Hg (10.6 kPa).  Which of the following should the nurse implement first?

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress.  While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration.  What immediate action does the RN take to correct the problem?

The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma.  Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones?

The charge nurse evaluates the care provided by a new registered nurse (RN) for a client receiving mechanical ventilation (MV).  Which action by the new RN indicates the need for further education?

The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator.  What is the priority nursing diagnosis (ND)?

A self-employed auto mechanic is diagnosed with carbon monoxide poisoning.  Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air.  What is the nurse's priority action?

A client with chronic kidney disease has a large pleural effusion.  What findings characteristic of a pleural effusion does the nurse expect?  Select all that apply.

The home health nurses visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago.  The client has less of a productive cough at night but now reports sharp chest pain with inspiration.  Which finding is most important for the nurse to report to the health care provider?

The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days.  During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP).  Which of the following manifestations does the nurse assess as the best indicator of VAP?

The nurse assesses a client with a history of cystic fibrosis who is being admitted due to a pulmonary exacerbation.  Which assessment finding requires immediate action by the nurse?

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days.  Which parameter monitored by the nurse best indicates the effectiveness of treatment?

A client has an allergy skin test that is positive for dust mites.  The nurse provides instruction on environmental interventions the client can use to control symptoms by reducing exposure to this allergen.  Which intervention would be described in this teaching?

The nurse cares for a client with a pulmonary embolism.  Which of the following clinical manifestations would the nurse anticipate?  Select all that apply.

The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy.  The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest.  Which action by the nurse is appropriate?  Click on the exhibit button for additional information.

A client is admitted with an exacerbation of asthma following a respiratory viral illness.  Which clinical manifestations characteristic of a severe asthma attack does the nurse expect to assess?  Select all that apply.

An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week.  Which factor puts the client at greatest risk for developing pneumonia?

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?

When an unlicensed assistive personnel (UAP) assists a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidently falls over and cracks.  The UAP immediately reports this incident to the nurse.  What is the nurse's immediate action?

The nurse is teaching an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea.  Which interventions would be most effective?  Select all that apply.

A nurse is reviewing the laboratory results of a client admitted for an asthma exacerbation.  Elevation of which of these cells indicates that the client's asthma may have been triggered by an allergic response?

client comes to the emergency department and reports headache, nausea, and shortness of breath after being stranded at home without electricity due to severe winter weather.  While collecting a history, which question is most important for the nurse to ask?

The nurse caring for a client with left lobar pneumonia responds to an alarm from the continuous pulse oximeter.  The client is short of breath with an oxygen saturation of 78%.  After applying oxygen, the nurse should place the client in which position to improve oxygenation?

The nurse assesses a client with fever and productive cough for the last 10 days.  Which findings support the presence of pneumonia?  Select all that apply.

The nurse is gathering data on a client with obstructive sleep apnea.  Which findings are consistent with this client's diagnosis?  Select all that apply.

The nurse auscultates the lung sounds of a client with shortness of breath, Coarse crackles (loud, low-pitched bubbling) are head.  Based on the sounds heard, which action would the nurse anticipate?  

The nurse is teaching self-care management to a client experiencing an outbreak of genital herpes.  Which statement by the client indicates a need for further teaching?

The nurse is reinforcing instructions to a client being discharged from the clinic with a diagnosis of acute prostatitis.  Which statement by the client indicates an understanding of the instructions?

The medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing.  The client becomes confused and restless, and respirations are 30/min.  What is the nurse's next action?

During a routine clinic visit, the nurse is providing education to a 24-year-old female client with Marfan syndrome and aortic root dilation.  Which statement made by the nurse is appropriate?

A client on a medical-surgical unit is receiving heparin therapy.  Platelet levels decreased from 230,000/mm³ (230 × 10⁹/L) 2 days ago to 80,000/mm³ (80 × 10⁹/L) today.  Which nursing actions are appropriate?  Select all that apply.

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD).  The nurse anticipates which laboratory results for this client?

Which signs are consider as Early signs of a hemolytic include?

Which signs are consider as late signs of a hemolytic include? select all that apply

The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home.  Which of the following actions by the nurse are appropriate?  Select all that apply.

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?

The nurse is teaching general skin care guidelines to a client receiving teletherapy (external beam radiation therapy).  Which statements does the client make that indicate proper understanding of the teaching?  Select all that apply.

In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis.  The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump.  Which action should the nurse expect to implement?

The nurse assesses a client with Cushing syndrome.  Which clinical manifestations should the nurse expect?  Select all that apply.

In the intensive care unit, the nurse cares for a client who develops diabetes insipidus (DI) 2 days after pituitary adenoma removal via hypophysectomy.  Which intervention should the nurse implement?

The clinic nurse is reviewing the laboratory results of a 35-year-old client who reports fatigue for the last month.  Based on the laboratory results, which additional clinical manifestations would the nurse expect?  Click on the exhibit button for additional information.  Select all that apply.

The nurse cares for a client who is experiencing exophthalmos as a complication of Graves' disease.  Which nursing action(s) should be included in the client's plan of care?  Select all that apply.

The nurse cares for a client with type 2 diabetes mellitus.  The client is alert and oriented but also shaky, pale, and diaphoretic.  The client's fingerstick blood glucose is 50 mg/dL (2.8 mmol/L).  Which of the following is the best next step the nurse can take?

A client diagnosed with septic shock has an upward-trending glucose level (180-225 mg/dL [10.0-12.5 mmol/L]) requiring control with insulin.  The client's spouse asks why insulin is needed as the client is not a diabetic.  What is the most appropriate response by the nurse?

The nurse practicing in an out-patient clinic cares for a client recently diagnosed with hyperthyroidism.  Which diet-related teaching should the nurse add to the client's plan of care?  Select all that apply.

A client is diagnosed with diabetic ketoacidosis (DKA).  The client reports frequent urination, thirst, and weakness.  The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes.  What is the priority nursing diagnosis (ND) at this time?

The nurse cares for a client admitted to the hospital due to confusion.  The client has a nonmetastatic lung mass and a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH).  Which action(s) should the nurse expect to implement?  Select all that apply.

The nurse is performing an initial assessment on a client diagnosed with Addison's disease.  Which assessment findings should the nurse anticipate?  Select all that apply.

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA).  After checking the blood glucose, which prescription should the nurse implement first?

The nurse cares for a client with type I diabetes mellitus.  Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy?

A client is admitted to the intensive care unit with diagnoses of a brain tumor complicated by transient diabetes insipidus.  Which client data related to this complication should the nurse expect?  Select all that apply.

The nurse assesses a female client with a diagnosis of primary adrenal insufficiency (Addison disease).  The nurse recognizes which finding associated with the disease?

A client with type I diabetes mellitus is brought to the emergency department by his wife.  The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak.  The nurse should anticipate implementation of which prescription(s)?  Select all that apply.

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone.  Which data should the nurse expect with the onset of this condition?  Select all that apply.

The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state.  The nurse understands which characteristics are commonly associated with this complication?  Select all that apply.

The nurse is caring for a 72-year-old client with hypothyroidism admitted to the emergency department for altered mental status.  The client lives alone but has not taken medications or seen a health care provider for several months.  Which action is the priority?  Click on the exhibit button for additional information.

The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes.  Which instructions should the nurse include?  Select all that apply.

The nurse is caring for a client with acute pericarditis.  Which clinical finding would require immediate intervention by the nurse?

Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis?

A client with newly diagnosed chronic heart failure is being discharged home.  Which statement(s) by the client indicate a need for further teaching by the nurse?  Select all that apply.

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum.  What would the nurse anticipate when auscultating the breath sounds of this client?

A client is seen following a motor vehicle collision.  An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital.  The IV line is now infusing at 200 mL/hr.  Which assessment finding alerts the nurse to the development of hypovolemic shock?

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease.  Which statements indicate a correct understanding of the instructions?  Select all that apply.

A nurse caring for a client with a central venous catheter (CVC) enters the client's room and notes that the CVC is dislodged and lying in the client's bed linens.  The client appears cyanotic and is tachypneic and diaphoretic.  Which of the following actions by the nurse are appropriate?  Select all that apply.

A client is in suspected shock state from major trauma.  Which parameters best indicate the adequacy of peripheral perfusion?  Select all that apply.

The nurse is monitoring a client following a radiofrequency catheter ablation.  The nurse notes that the P waves are not associated with the QRS complexes on the cardiac monitor.  Which intervention is most appropriate at this time?  Click on the exhibit button for additional information.

What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) of 24 mm Hg?  Select all that apply.

The nurse responds to a call for help from another staff member.  Upon entering the client's room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team.  What action by the arriving nurse is the priority?

The nurse is caring for a client who just had a permanent ventricular pacemaker inserted.  The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat.  How should the nurse assess for mechanical capture of the pacemaker?

A client involved in a motor vehicle collision reports severe pelvic and right heel pain.  While waiting for imaging, the nurse assesses the client.  Which finding should the nurse report to the health care provider immediately?

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis.  The client has oliguria, dark amber urine, and muscle pain.  The nurse should implement which prescription first?

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone fractures.  Which findings does the nurse expect to assess to support this diagnosis?  Select all that apply.

The nurse has provided education for a client with newly diagnosed ankylosing spondylitis.  Which client statements indicate a correct understanding of teaching?  Select all that apply.

A client with advanced osteoarthritis is admitted for right total knee arthroplasty.  Which characteristic manifestations does the nurse expect to assess in this client?  Select all that apply.

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?

A nurse is caring for a client diagnosed with rheumatoid arthritis (RA).  Which assessment finding does the nurse expect to assess?

The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom management.  Which of the following client statements indicates a need for further teaching?

client comes to the clinic for a follow-up visit after a Billroth II surgery (gastrojejunostomy).  The client reports occasional episodes of sweating, palpitations, and dizziness 30 minutes after eating.  Which nursing action is most appropriate?

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever.  What instruction is most important for the nurse to give to the client?

The nurse is caring for a client with acute diverticulitis who has nausea, vomiting, and rates pain as 8 on a scale of 0-10.  Which of the following interventions should be included in the plan of care?  Select all that apply.  Click the exhibit button for additional information.