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WorksheetsNursing Assessment and Client Care Quiz
Total questions: 100
Worksheet time: 50mins
The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema?
Compress the flank and upper buttocks.
Measure the client's abdominal girth.
Gently palpate the lower abdomen.
Apply light pressure over the shins.
The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information?
A description of inflammation, infection, and tumors.
Continuous visualization of intracranial neoplasms.
Imaging of tumors without exposure to radiation.
An image that describes metastatic sites of cancer.
A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. Which information is best for the nurse to provide? (Select all that apply.)
Only marijuana cigarettes affect sperm count.
Smoking can decrease the quantity and quality of sperm.
The first semen analysis should be repeated to confirm sperm counts.
Cessation of smoking improves general health and fertility.
Sperm specimens should be collected in 2 subsequent days.
A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and irritability. Which symptom is not frequently associated with PMS?
Heart palpitations.
Anorexia.
Hypersomnia.
Stress incontinence.
Which of the following are characteristic features of premenstrual syndrome (PMS)? (Select all that apply.)
Behavioral changes/irritability
Increased appetite and food cravings
Oliguria or enuresis
Heart palpitations
Which protocols should a nurse implement to prepare a client with a recent history of blood in his stools for a proctoscopy/sigmoidoscopy? (Select all that apply.)
Obtain consent for the procedure.
Initiate preoperative sedation.
Begin fast the morning of the procedure.
Administer an enema before the procedure.
Provide a clear-liquid diet 48 hours before the procedure.
What is the rationale for providing a clear liquid diet and administering an enema before a proctoscopy/sigmoidoscopy?
To prevent dehydration
To reduce the risk of infection
To ensure the bowel is clear for visualization
To increase patient comfort
Which discharge instruction should a nurse provide to a client with chronic prostatitis to reduce the risk of spreading infection to other areas of the urinary tract?
Wear a condom when having sexual intercourse.
Avoid consuming alcohol and caffeinated beverages.
Empty the bladder completely with each voiding.
Have intercourse or masturbate at least twice a week.
Why does regular intercourse or masturbation help reduce the risk of further infection in clients with chronic prostatitis?
It increases antibiotic absorption.
It decreases the number of microorganisms present in the prostate.
It prevents urinary retention.
It improves immune function.
A client’s serum potassium level is 4.5 mEq/L after coronary artery bypass surgery. Which action should the nurse implement?
Notify the healthcare provider.
Decrease the IV solution flow rate.
Document the finding as the only action.
Administer potassium replacement as prescribed.
Coronary artery bypass surgery graft (CABG) places a client at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy. What is the recommended serum potassium level to avoid dysrhythmias in these clients?
Between 2 and 3 mEq/L.
Between 4 and 5 mEq/L.
Between 6 and 7 mEq/L.
Between 1 and 2 mEq/L.
A male client is admitted after falling from his bed. The healthcare provider tells the family that he has an incomplete fracture of the humerus. Which type of fracture should the nurse explain from these findings?
A straight fracture line that is also a simple, closed fracture.
A nondisplaced fracture line that wraps around the bone.
A complete fracture that also punctures the skin.
A fracture that bends or splinters part of the bone.
A client with primary dysmenorrhea has several medications at home. She calls the clinic to ask the nurse which medication she should use for her pain. Which option should the nurse recommend as the first choice in the management of this client's pain?
Aspirin.
Codeine.
Ibuprofen.
Acetaminophen.
Which intervention should the nurse implement that best confirms the placement of an endotracheal tube (ETT)?
Use an end-tidal CO2 detector.
Auscultate for bilateral breath sounds.
Obtain pulse oximeter reading.
Check symmetrical chest movement.
A client is admitted after a blunt abdominal injury. Which assessment finding requires immediate action by the nurse?
Radiating abdominal pain with left lower quadrant palpation.
Grimacing after palpation of the right hypochondriac region.
Rebound tenderness with abdominal palpation.
Mild discomfort with deep inspiration.
Which of the following is indicated by bluish periumbilical skin discoloration in a client with blunt abdominal injury?
Intraperitoneal hemorrhage
Dehydration
Hypoglycemia
Pulmonary embolism
A client with Meniere's disease is experiencing severe vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement?
Encourage fluids to 3000 mL per day.
Change the client's position every two hours.
Keep the head of the bed elevated by 30 degrees.
Turn off the television and darken the room.
Why should visual stimuli and rotational movements be minimized for a client with Meniere's disease during an acute attack?
To prevent dehydration
To decrease vertigo symptoms
To improve appetite
To increase blood pressure
A nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.)
Nail polish, wedding band, left leg brace
Nail polish, contact lenses, partial dentures
Hearing aids, wedding band, left leg brace
Contact lenses, hearing aids, nail polish
What is the priority nursing problem for an older female client admitted with atrophic vaginitis and perineal cutaneous candidiasis?
Risk for dehydration
Risk for injury
Risk for impaired mobility
Risk for constipation
Which of the following is a primary nursing problem supported by manifestations such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia in menopausal women?
Impaired comfort.
Disturbed body image.
Ineffective health maintenance.
Impaired physical mobility.
Which findings are within the expected parameters of a normal urinalysis for an older adult? (Select all that apply.)
pH 6, Nitrate small, Protein small, Sugar negative, Bilirubin negative, Specific gravity 1.015
pH 8, Nitrate positive, Protein large, Sugar positive, Bilirubin positive, Specific gravity 1.050
pH 4, Nitrate negative, Protein large, Sugar positive, Bilirubin positive, Specific gravity 1.000
pH 7, Nitrate positive, Protein moderate, Sugar negative, Bilirubin positive, Specific gravity 1.040
Why is it important for a nurse to minimize lying on the affected side and include prone positioning in the care plan for a client with right-sided hemiplegia after an acute stroke?
To prevent flexion contractures of the hips and promote optimal functioning and ambulation.
To increase the risk of pressure ulcers.
To decrease the risk of urinary tract infection.
To improve respiratory function only.
Which positioning should the nurse use to maintain optimal functioning for a client with an acute stroke resulting in right-sided hemiplegia?
Mid-Fowler's with knees supported.
Supine with trochanter rolls to the hips.
Lateral position alternating sides every 2 hours.
Left lateral, supine, brief periods on the right side, and prone.
When moving a client on a ventilator away from an oxygen wall outlet and fire source, which action should the nurse take to maintain respirations?
Use a bag-valve-mask resuscitator while removing the client from the area.
Tell another staff member to bring extinguishing equipment to the bedside.
Close the doors to the client's area when attempting to extinguish the fire.
Implement an emergency protocol to remove the client from the ventilator.
On the scheduled day of surgery, what should the nurse implement for a client with type 1 diabetes mellitus (DM) who is NPO?
Obtain a prescription for an adjusted dose of insulin.
Administer an oral antidiabetic agent.
Give an insulin dose using the parameters of a sliding scale.
Withhold insulin while the client is NPO.
A college student with a vaginal infection and "cottage-cheese" discharge should have which prescription implemented first?
Instill the first dose of nystatin vaginally per applicator.
Cleanse the perineum with warm soapy water 3 times per day.
Perform glucose measurement using a capillary blood sample.
Obtain a blood specimen for sexually transmitted diseases (STDs).
After the removal of a chest tube, which intervention has the highest priority and should be anticipated by the nurse?
Prepare the client for a chest x-ray at the bedside.
Review arterial blood gases after removal.
Elevate the head of the bed to 45 degrees.
Assist with disassembling the drainage system.
Why should a chest x-ray be performed immediately after the removal of a chest tube?
To ensure lung expansion has been maintained after its removal.
To check for infection at the removal site.
To confirm the absence of fluid in the pleural space.
To assess the patient's pain level.
Which of the following is the most appropriate advice for a couple dealing with infertility to help them cope with their situation?
Tell your friends and family so that they can help you.
Talk only to other friends who are infertile since only they can help.
Start adoption proceedings immediately since obtaining an infant is very difficult.
Do not discuss your feelings with anyone.
Which effect is characteristic of NSAIDs used for treating rheumatoid arthritis?
Inflammation is reduced by inhibiting prostaglandin synthesis.
Production of replacement cartilage is stimulated.
Further destruction of the articular cartilage is prevented.
Bradykinin is inhibited, thereby reducing acute and chronic pain.
A nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further?
Increase in abdominal fat deposits.
Thinning hair and dry scalp.
Increase in appetite and taste-bud acuity.
Increase in muscle tone but decreased muscle strength.
When teaching a client with breast cancer about the prescribed radiation therapy for treatment, which information is important to include?
Dry, itchy skin changes may occur.
There is a possibility of long bone pain.
Permanent pigment changes to the breast may result.
A low-residue diet may be ordered to reduce the likelihood of diarrhea.
Which finding is most important for the nurse to further assess in a client with a chest tube attached to suction and a closed drainage system?
Upper chest subcutaneous emphysema.
Tidaling (fluctuation) of fluid in the water-seal chamber.
Constant air bubbling in the suction-control chamber.
Pain rated "8" (0 to 10) at the insertion site.
After noting asymmetrical expansion of the chest wall in a client with chest trauma, which action should the nurse implement next?
Auscultate the lungs bilaterally.
Inspect the overall skin color.
Palpate for tactile fremitus.
Percuss the chest for resonance.
Which nursing intervention should be implemented in the immediate postprocedural period for a client who has had a bronchoscopy?
Allow the client nothing by mouth until the gag reflex returns.
Keep the client on bed rest for eight hours.
Check vital signs every 15 minutes for two hours.
Encourage fluid intake to promote the elimination of the contrast media.
What is the best response for the nurse to provide to a client concerned about resuming sexual activity after an acute myocardial infarction (MI)?
Sexual intercourse can be strenuous on your heart, but closeness and intimacy, such as holding and cuddling, can be maintained with your wife.
You should avoid all forms of intimacy until your next cardiac follow-up.
Sexual activity is not recommended for at least six months after an MI.
You should only resume sexual activity if you feel completely free of symptoms.
After a myocardial infarction (MI), when can sexual activity typically be resumed?
Whenever you and your partner feel ready, as the sexual response is more emotional than physical.
Only after six months of complete rest.
Never, as it is too risky for heart patients.
Only after a stress test is performed.
What should a nurse do first when a male client presents with penile discharge and painful, burning urination?
Collect a culture of the penile discharge.
Palpate the inguinal lymph nodes gently.
Observe for scrotal swelling and redness.
Express the discharge to determine color.
Which observation should alert the nurse to call the Rapid Response Team (RRT) for a client who is two days postoperative?
Pulse change from 85 to 160 beats/minute lasting more than 10 minutes.
Fresh bleeding noted on abdominal surgical wound dressing.
Temperature of 103.1 °F (39.5 °C) and WBC count of 16,000 mm3.
Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mmHg.
Which assessment finding in a client with viral gastroenteritis should be reported to the healthcare provider?
Rebound abdominal tenderness over the right lower quadrant.
Dry mucous membranes and lips.
Dizziness when client ambulates from a sitting position.
Poor skin turgor over the client's wrist.
While caring for a client who has esophageal varices, which nursing intervention is most important for the nurse to implement?
Monitor infusing IV fluids and any replacement blood products.
Prepare for esophagogastroduodenoscopy (EGD).
Maintain the client on strict bedrest.
Insert a nasogastric tube (NGT) for intermittent suction.
After a transurethral resection of the prostate (TURP), a nurse determines the client’s urinary catheter is not draining. What should the nurse implement?
Reposition the catheter drainage tubing.
Encourage the client to drink oral fluids.
Irrigate the catheter.
Change drainage unit tubing.
A nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately?
Large amounts of expelled flatus with mucus.
Tympanic abdomen and hyperactive bowel sounds.
Increased abdominal pain with rebound tenderness.
Complaint of feeling weak with watery diarrheal stools.
Which preexisting diagnosis places a client at the greatest risk of developing superior vena cava syndrome?
Carotid stenosis.
Steatosis hepatitis.
Metastatic cancer.
Clavicular fracture.
What is superior vena cava syndrome most likely to occur with?
Metastatic cancer from a primary tumor in the upper lobe of the right lung
Heart failure due to hypertension
Chronic obstructive pulmonary disease (COPD)
Acute myocardial infarction
A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. After receiving 6 ounces of orange juice, the client's capillary glucose is 74 mg/dL after 15 minutes. What action should the nurse take?
Provide cheese and bread to eat.
Obtain a specimen for a serum glucose level.
Administer insulin per sliding scale.
Collect a glycosylated hemoglobin specimen.
A client is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision. Which finding requires immediate action by the nurse?
Chest x-ray indicating a mediastinal shift.
Serum amylase of 132 units/L.
Serum sodium of 134 mEq/L.
Abdominal x-ray with air noted throughout intestines.
Which laboratory result should the nurse assess as a normal value for the two-hour postprandial result in a young adult undergoing an oral glucose tolerance test (OGTT)?
140 mg/dL
160 mg/dL
180 mg/dL
200 mg/dL
When planning care for a client with right renal calculi, which nursing problem has the highest priority?
Impaired urinary elimination related to the obstructed flow of urine.
Acute pain related to movement of the stone.
Risk for infection related to urinary stasis.
Deficient knowledge related to dietary restrictions.
What is the nursing problem of the highest priority for a client with renal calculi?
Acute pain related to the renal calculi's movement.
Risk for infection related to urinary stasis.
Deficient knowledge related to the need for prevention of recurrence of calculi.
Impaired urinary elimination.
A client with acute appendicitis is experiencing anxiety and loss of sleep about missing the final examination week at college. Which outcome is most important for the nurse to include in the plan of care?
Achieve a sense of control.
Sleeping six to eight hours.
Utilize problem-solving skills.
Increased focus of attention.
A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, nonhemolytic reaction. Which assessment finding is most important for the nurse to identify?
Flushed skin and headache.
Increased anxiety since the transfusion began.
Drowsiness after receiving diphenhydramine.
Reports feeling cold.
A client has been told that there is cataract formation over his both eyes. Which finding should the nurse expect when assessing the client?
Decreased color perception.
Presence of floaters.
Loss of central vision.
Reduced peripheral vision.
Which assessment finding is of greatest concern to the nurse who is caring for a client with stomatitis?
Cough brought on by swallowing.
Mild oral discomfort.
Slight redness of the gums.
Dry mouth.
Which of the following is a sign of dysphagia that should be reported immediately in a client with stomatitis?
Sore throat caused by speaking.
Painful and dry oral cavity.
Unintended weight loss.
A cough brought on by swallowing.
A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk factor for myocardial infarction?
Oral contraceptives.
Senile osteopenia.
Levothyroxine therapy.
Pernicious anemia.
A nurse is caring for a client with non-Hodgkin’s lymphoma who is receiving chemotherapy. The client’s platelet count is 10,000/mL. Which action should the nurse implement?
Encourage fluids to 3000 mL/day.
Check stools for occult blood.
Provide oral hygiene every 2 hours.
Check for fever every 4 hours.
A client with acute osteomyelitis has undergone surgical debridement. How long should the nurse communicate that antibiotics will need to be administered?
Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis.
Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year.
Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks.
Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks.
Which client should be further assessed for an ectopic pregnancy?
A 24-year-old with shoulder and lower abdominal quadrant pain.
A 40-year-old with a history of hypertension.
A 30-year-old with a history of migraine headaches.
A 28-year-old with upper back pain.
A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for which condition?
Ectopic pregnancy.
Appendicitis.
Gallstones.
Urinary tract infection.
A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate is 70 beats per minute, respirations are 18 breaths per minute and blood pressure is 125/75 mmHg. Which action should the nurse implement next?
Administer the medication.
Inform the healthcare provider.
Review the vital sign flowsheet.
Reassess the apical heart rate.
Which information should the nurse offer to facilitate the client’s adjustment to HIV infection after a positive test result?
Discuss retesting to verify the results, which will ensure continuing contact.
Inform the client how to protect sexual and needle-sharing partners.
Teach the client about the medications that are available for treatment.
Identify the need to test others who have had risky contact with the client.
To prevent hospital-associated fungal infection (candidiasis) in a nursing home resident, which protocol should the nurse review with the rest of the staff?
Follow contact isolation procedures.
Wash hands after caring for the client.
Wear gloves when providing personal care.
Restrict pregnant staff or visitors into the room.
Which organism causes an infection that is part of the normal flora on the skin of most adults and can be prevented by good handwashing?
Candida albicans.
Staphylococcus aureus.
Escherichia coli.
Pseudomonas aeruginosa.
What is the main purpose of prescribing a high-protein, high-fat, low-carbohydrate diet with limited fluids for a client recovering from gastric surgery?
It is quickly digested.
It does not cause diarrhea.
It does not dilate the stomach.
It is slow to leave the stomach.
When providing care to a client who has returned to the unit after a mastectomy, which instruction should the nurse give to the unlicensed assistive personnel (UAP) regarding the client’s arm on the operative side?
Elevate the arm with an IV infusing on the operative side with a pillow.
Apply the blood pressure cuff to the arm on the non-operative side.
Position the arm on the operative side close to the body.
Collect a fingerstick blood specimen from the arm on the operative side.
A client with chest pain, dizziness, and vomiting is admitted for evaluation of Acute Coronary Syndrome (ACS). Which cardiac biomarker is most specific and sensitive for myocardial damage?
Creatine Kinase (CK-MB).
Serum troponin.
Myoglobin.
Ischemia-modified albumin.
Why should blood pressure readings be obtained from the arm on the nonoperative side after a mastectomy?
To prevent infection.
To reduce the risk of injury to the extremity with compromised lymphatic drainage.
To avoid pain.
To ensure accurate readings.
Which of the following assessment findings should a nurse identify and document as consistent with peptic ulcer disease (PUD)? (Select all that apply)
Hematemesis.
Gastric pain on an empty stomach.
Colic-like pain with fatty food ingestion.
Intolerance of spicy foods.
Diarrhea and stearrhea.
A nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action?
Assessment of the client's vital signs.
Document the finding as the only action.
Determine the time the client last voided.
Insert a rectal tube for the passage of flatus.
During the assessment of a client who is 24 hours posthemicolectomy with a temporary colostomy, the nurse determines that the client’s stoma is dry and dark red in color. Which action should the nurse implement?
Notify the surgeon.
Document the assessment.
Secure a colostomy pouch over the stoma.
Place petrolatum gauze dressing over the stoma.
A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas pains. Which nursing intervention should be implemented?
Obtain a prescription for a laxative.
Withhold all oral fluid and food.
Encourage the client to ambulate.
Increase the dose of morphine sulfate.
Which of the following actions helps minimize postoperative abdominal distention in a client after abdominal surgery?
Assist the client to ambulate in the hall.
Administer a high-fat diet.
Restrict all fluids.
Keep the client on bed rest.
Which physiological factors can produce ulceration related to peptic ulcer disease (PUD)? (Select all that apply.)
Vagal stimulation; An increased level of stress; Decreased duodenal inhibition; Hypersecretion of hydrochloric acid; An increased number of parietal cells.
Only vagal stimulation and increased stress.
Only decreased duodenal inhibition and hypersecretion of hydrochloric acid.
Only an increased number of parietal cells.
A nurse is evaluating if a client with a cuffed tracheostomy tube can tolerate cuff deflation to promote speaking and swallowing. Which action should the nurse implement?
Observe the client for coughing colored sputum after drinking a small amount of colored water.
Ask the client to try to speak.
Assess for respiratory distress.
Auscultate for pulmonary crackles after the client drinks a small amount of clear water.
A client asks how a percutaneous endoscopic gastrostomy (PEG) tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different?
Method of insertion.
Location of the tubes.
Diameter of the tubes.
Material of the tubes.
What is the main difference between a PEG tube and a GT tube?
The method of insertion
The type of medication used
The length of the tube
The location of the incision
Why is a PEG tube more commonly used than a GT tube?
It does not require general anesthesia and is less invasive
It is more effective in delivering medication
It is cheaper to produce
It can be inserted without any incision
A client with tuberculosis (TB) complains about taking "so many pills" in a combination drug regimen. What should the nurse explain about the prescribed treatment?
The development of resistant strains of TB is decreased with a combination of drugs.
The treatment time is increased to 12 months with this regimen.
Side effects are minimized with a combination of drugs.
The medication regimen can be stopped once symptoms improve.
Why is combination therapy necessary in the treatment of tuberculosis (TB)?
To decrease the development of resistant strains of TB and ensure treatment efficacy
To reduce the cost of treatment
To minimize the number of pills taken daily
To avoid the need for hospitalization
A client returns to the unit after a percutaneous coronary intervention (PCI) with balloon angioplasty and complains of acute chest pain. Which action should the nurse implement next?
Give a sublingual nitroglycerin tablet.
Inform the healthcare provider.
Obtain a 12-lead electrocardiogram.
Administer prescribed analgesic.
After a PCI with balloon angioplasty, why is nitroglycerin administered to a client experiencing acute chest pain?
To dilate the coronary arteries and increase myocardial oxygenation
To reduce blood pressure only
To prevent infection at the incision site
To decrease the risk of blood clots in the legs
A client with a traumatic brain injury is admitted after hitting his head against a brick wall. Which finding is most important for the nurse to assess further?
Dizziness, nausea, and transient confusion.
A scalp laceration oozing blood.
Serosanguineous nasal drainage.
Headache rated "10" on a 0 to 10 scale.
A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. What should the nurse evaluate?
Determine the client's level of discomfort using a pain rating scale.
Ask the client about her past experience with chronic pain.
Observe the client's facial expressions for pain and discomfort.
Evaluate the client's ability to adjust the voltage to control pain.
Which is the primary nursing problem for a client with asymptomatic primary syphilis?
Acute pain.
Risk for injury.
Sexual dysfunction.
Deficient knowledge.
A client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client?
A graduate registered nurse (RN) with three weeks of experience.
The registered nurse (RN) case manager for the unit with 1 year's experience.
A "floating" registered nurse (RN) with five years of nursing experience.
A Korean-American practical nurse (PN) with six years of nursing experience.
The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome?
Prevent the formation of effusion fluid.
Remove fluid from the intrapleural space.
Debulk tumor to maintain patency of air passages.
What is the primary reason for teaching a client with emphysema to perform pursed lip breathing?
Decreases respiratory rate.
Increases O2 saturation throughout the body.
Conserves energy while ambulating.
Promotes CO2 elimination.
Which genitourinary system complication should a nurse include in teaching for a client diagnosed with peripheral arterial disease (PAD)?
Altered sexual response.
Sterility.
Urinary incontinence.
Decreased pelvic muscle tone.
A client with a myocardial infarction develops increased pulmonary congestion, an increased heart rate, and cold, clammy skin. Which action should the nurse implement?
Notify the healthcare provider.
Increase the IV flow rate.
Place the client in the supine position.
Prepare the client for emergency echocardiography.
What is the purpose of instilling a sclerosing agent to create pleurodesis after a pneumonectomy?
To relieve pain.
To prevent the accumulation of pleural fluid.
To increase lung capacity.
To promote wound healing.
Which assessment should a nurse perform for a client with a history of atrial fibrillation who is admitted with sudden onset of shortness of breath and a new irregular heart rhythm?
Check for a pulse deficit.
Palpate the apical impulse.
Inspect jugular vein pulse.
Examine for a carotid bruit.
What is the best response for a nurse to provide to a client diagnosed with human papillomavirus infection (HPV) who is angry and does not want to inform her ex-boyfriend that he is infected?
Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection.
You do not have to tell him because this is not a reportable disease.
Because there is no cure for this disease, telling him is of no benefit to him or to you.
You should tell him, so he can feel as guilty and miserable as you do now, knowing that you have this disease.
A female client admitted with abdominal pain is diagnosed with cholelithiasis. What is the most common treatment plan the nurse should explain to the client?
Cholecystectomy via laparoscopy.
Rest with liquid diet only.
Drugs such as ursodiol.
LaVeen vena caval shunt.
The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. Which is the priority nursing problem that should guide the discharge instruction plan?
Acute pain.
Risk for infection.
Disturbed body image.
Risk for deficient fluid volume.
Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer?
Neisseria gonorrhoea.
Chlamydia trachomatis.
Herpes simplex virus.
Human papillomavirus.
The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?
Perform active range of motion three times daily.
Monitor for Battle's sign every four hours.
Teach measures to avoid the Valsalva maneuver.
Maintain the head of bed in a flat position.
The nurse is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm3 and a platelet count of 160,000/mm3. Which intervention is the primary focus in the client's plan of care for the nurse to implement?
Assist with frequent ambulation.
Encourage visitors to visit.
Maintain strict protective precautions.
Avoid peripheral injections.
After a liver biopsy is performed at the bedside, which nursing intervention is most important for the nurse to implement?
Position the client on the left side with a pillow placed under the costal margin.
Assist the client with voiding immediately after the procedure.
Evaluate vital signs every 15 minutes x 2, then every 30 minutes x 4, then hourly x 4.
Ambulate the client 3 times in the first hour with a pillow held at the abdomen.
