An adult woman with primary Raynaud D. Continue to monitor the fingers until color returns to normal
phenomenon develops pallor and then
cyanosis of her fingers. After warming her
hands, the fingers turn red and the client
reports a burning sensation. What action
should the nurse take?
A. Apply a cool compress to the affected
fingers for 20 minutes
B. Secure a pulse oximeter to monitor the
client's oxygen saturation
C. Report the finding to the healthcare
provider as soon as possible
D. Continue to monitor the fingers until
color returns to normal
After a computer tomography (CT) scan C. Prepare a dose of epinephrine (Adrenalin)
with intravenous contrast medium, a client
returns to the room complaining of
shortness of breath and itching. Which
intervention should the nurse implement?
A. Call respiratory therapy to give a
breathing treatment
B. Send another nurse for an emergency
tracheotomy set
C. Prepare a dose of epinephrine
(Adrenalin)
D. Review the client's complete list of
allergies
,After a hospitalization for Syndrome of A. Reorient client to his room
Inappropriate Antidiuretic Hormone
(SIADH), a client develops pontine
myelinolysis. Which intervention should the
nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises
A cardiac catherterization of a client with C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting
heart disease indicates the following through to the heart muscle.
blockages: 95% proximal left anterior
descending (LAD), 99% proximal circumflex,
and ? % proximal right coronary artery
(RCA). The client later asks the nurse "what
does all this mean for me?" What
information should the nurse provide?
A. Blood supply to the heart is diminished
by artherosclerotic lesions, which
necessitate lifestyle changes.
B. Blood vessels supplying the pumping
chamber have blockages indicating a past
heart attack.
C. Three main arteries have major
blockages, with only 1 to 5% of blood flow
getting through to the heart muscle.
D. The heart is not receiving enough blood,
so there is a risk of heart failure and fluid
retention.
, A client admitted to a surgical unit is being D. elevate HEAD of bed 60 to 90 degrees
evaluated for an intestinal obstruction. The
healthcare provider prescribes a
nasogastric tube (NGT) to be inserted and
placed to intermittent low wall suction.
Which intervention should the nurse
implement to facilitate proper tube
placement?
A. Soak nasogastric tube in warm water
B. Insert tube with client's head tilted back
C. Apply suction while inserting tube
D. Elevate head of bed 60 to 90 degrees
A client is brought to the ED by ambulance A. Breath sounds over bilateral lung fields.
in cardiac arrest with cardiopulmonary
resuscitation (CPR) in progress. The client is
intubated and is receiving 100% oxygen per
self-inflating (ambu) bag. The nurse
determines that the client is cyanotic, cold,
and diaphoretic. Which assessment is most
important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature
A client who has a history of D. Further decline in level of consciousness
HYPOTHYROIDISM was initially admitted
with lethargy and confusion. Which page 1518 lippincott
additional finding warrants the most
immediate action by the nurse?
A. Facial puffiness and periorbital edema
B. Hematocrit of 30%
C. Cold and dry skin
D. Further decline in level of consciousness
phenomenon develops pallor and then
cyanosis of her fingers. After warming her
hands, the fingers turn red and the client
reports a burning sensation. What action
should the nurse take?
A. Apply a cool compress to the affected
fingers for 20 minutes
B. Secure a pulse oximeter to monitor the
client's oxygen saturation
C. Report the finding to the healthcare
provider as soon as possible
D. Continue to monitor the fingers until
color returns to normal
After a computer tomography (CT) scan C. Prepare a dose of epinephrine (Adrenalin)
with intravenous contrast medium, a client
returns to the room complaining of
shortness of breath and itching. Which
intervention should the nurse implement?
A. Call respiratory therapy to give a
breathing treatment
B. Send another nurse for an emergency
tracheotomy set
C. Prepare a dose of epinephrine
(Adrenalin)
D. Review the client's complete list of
allergies
,After a hospitalization for Syndrome of A. Reorient client to his room
Inappropriate Antidiuretic Hormone
(SIADH), a client develops pontine
myelinolysis. Which intervention should the
nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises
A cardiac catherterization of a client with C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting
heart disease indicates the following through to the heart muscle.
blockages: 95% proximal left anterior
descending (LAD), 99% proximal circumflex,
and ? % proximal right coronary artery
(RCA). The client later asks the nurse "what
does all this mean for me?" What
information should the nurse provide?
A. Blood supply to the heart is diminished
by artherosclerotic lesions, which
necessitate lifestyle changes.
B. Blood vessels supplying the pumping
chamber have blockages indicating a past
heart attack.
C. Three main arteries have major
blockages, with only 1 to 5% of blood flow
getting through to the heart muscle.
D. The heart is not receiving enough blood,
so there is a risk of heart failure and fluid
retention.
, A client admitted to a surgical unit is being D. elevate HEAD of bed 60 to 90 degrees
evaluated for an intestinal obstruction. The
healthcare provider prescribes a
nasogastric tube (NGT) to be inserted and
placed to intermittent low wall suction.
Which intervention should the nurse
implement to facilitate proper tube
placement?
A. Soak nasogastric tube in warm water
B. Insert tube with client's head tilted back
C. Apply suction while inserting tube
D. Elevate head of bed 60 to 90 degrees
A client is brought to the ED by ambulance A. Breath sounds over bilateral lung fields.
in cardiac arrest with cardiopulmonary
resuscitation (CPR) in progress. The client is
intubated and is receiving 100% oxygen per
self-inflating (ambu) bag. The nurse
determines that the client is cyanotic, cold,
and diaphoretic. Which assessment is most
important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature
A client who has a history of D. Further decline in level of consciousness
HYPOTHYROIDISM was initially admitted
with lethargy and confusion. Which page 1518 lippincott
additional finding warrants the most
immediate action by the nurse?
A. Facial puffiness and periorbital edema
B. Hematocrit of 30%
C. Cold and dry skin
D. Further decline in level of consciousness
