The nurse is concerned that the client in a long-term care facility is experiencing retinal
detachment. Which intervention should the nurse implement first?
1. flush the eye thoroughly with saline solution and apply a pressure bandage
2. apply an eye shield to the affected eye and give a prescribed oral analgesic
3. notify the HCP; prepare for transport to a facility for ophthalmological care
4. patch both eyes and place the client in a prone position until blurring stops
3. The nurse should contact the HCP and secure an ophthalmological
evaluation promptly
The nurse is obtaining a hospital admission history for the client. Which statement should
prompt the nurse to consider that the client has chronic prostatitis?
1. I am having difficulty sustaining an erection
,2. I have pain with ejaculation during intercourse
3. I have been feeling pressure around my rectum
4. I don't think I am totally emptying my bladder
2. Both chronic bacterial prostatitis and chronic prostatitis/pelvic pain
syndrome manifest with ejaculatory pain
The nurse has just received the a.m. shift report. Which client would the nurse assess
first?
1. The client with a venous stasis ulcer who is complaining of pain.
2. The client with varicose veins who has dull, aching muscle cramps.
3. The client with arterial occlusive disease who cannot move the foot.
4. The client with deep vein thrombosis who has a positive Homans' sign.
3. The inability to move the foot means that a severe neurovascular
compromise has occurred, and the nurse should assess this client first.
The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin
drip, an intravenous anticoagulant. The healthcare provider orders warfarin (Coumadin),
an oral anticoagulant. Which action should the nurse take?
1.Discontinue the heparin drip prior to initiating the Coumadin.
2.Check the client's INR prior to beginning Coumadin.
3.Clarify the order with the health-care provider as soon as possible.
4.Administer the Coumadin along with the heparin drip as ordered.
, 4..It will require several days for the Coumadin to reach therapeutic levels; the
client will continue receiving the heparin drip until the therapeutic range can
be attained.
The client has a blood type of B negative. The client's family asks if they can donate
blood for the client. Which type of blood type would they need to be to be able to
donate? Select all that apply.
a. A+
b. B+
c. B-
d. O+
e. O-
f. AB+
c, e
A nurse is providing teaching for a client who has stage 2 HIV and is having difficulty
maintaining a normal weight. Which of the following statements by the client should
indicate to the nurse an understanding of the teaching?
a. I will choose to diet high in fat to help gain weight
b. I will be sure to eat 3 large meals a day
c. I will drink up to 1 liter of fluid a day
d. I will add high-protein foods to my diet
, D. high protein and high calorie is the best way to gain weight and maintain
health
· Which woman is at highest risk for cervical cancer?
o A 25-year-old woman who smokes and has multiple sexual partners
o A 40-year-old woman who had her first child at age 19 years and has been exposed to
HPV
o An 18-year-old woman who has just had her first sexual encounter
o An obese 30-year-old woman who has nutritional deficiencies and a family history of
cervical cancer
Answer: An obese 30-year-old woman who has nutritional deficiencies and a
family history of cervical cancer
· Rationale: Risk factors for cervical cancer include but are not limited to
smoking, multiple sexual partners, first child at an early age, exposure to HPV,
first sexual encounter at an early age, obesity, nutritional deficiencies, and a
family history of cervical cancer. All patients have risk factors, but the 40-year-
old woman has the most (three: obesity, nutritional deficiencies, and family
history)
The nurse is teaching the client with peripheral vascular disease. Which interventions
should the nurse discuss with the client? Select all that apply.
1.Wash your feet in antimicrobial soap.
2.Wear comfortable, well-fitting shoes
3.Cut your toenails in an arch.
4.Keep the area between the toes dry.
5.Use a heating pad when feet are cold.
detachment. Which intervention should the nurse implement first?
1. flush the eye thoroughly with saline solution and apply a pressure bandage
2. apply an eye shield to the affected eye and give a prescribed oral analgesic
3. notify the HCP; prepare for transport to a facility for ophthalmological care
4. patch both eyes and place the client in a prone position until blurring stops
3. The nurse should contact the HCP and secure an ophthalmological
evaluation promptly
The nurse is obtaining a hospital admission history for the client. Which statement should
prompt the nurse to consider that the client has chronic prostatitis?
1. I am having difficulty sustaining an erection
,2. I have pain with ejaculation during intercourse
3. I have been feeling pressure around my rectum
4. I don't think I am totally emptying my bladder
2. Both chronic bacterial prostatitis and chronic prostatitis/pelvic pain
syndrome manifest with ejaculatory pain
The nurse has just received the a.m. shift report. Which client would the nurse assess
first?
1. The client with a venous stasis ulcer who is complaining of pain.
2. The client with varicose veins who has dull, aching muscle cramps.
3. The client with arterial occlusive disease who cannot move the foot.
4. The client with deep vein thrombosis who has a positive Homans' sign.
3. The inability to move the foot means that a severe neurovascular
compromise has occurred, and the nurse should assess this client first.
The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin
drip, an intravenous anticoagulant. The healthcare provider orders warfarin (Coumadin),
an oral anticoagulant. Which action should the nurse take?
1.Discontinue the heparin drip prior to initiating the Coumadin.
2.Check the client's INR prior to beginning Coumadin.
3.Clarify the order with the health-care provider as soon as possible.
4.Administer the Coumadin along with the heparin drip as ordered.
, 4..It will require several days for the Coumadin to reach therapeutic levels; the
client will continue receiving the heparin drip until the therapeutic range can
be attained.
The client has a blood type of B negative. The client's family asks if they can donate
blood for the client. Which type of blood type would they need to be to be able to
donate? Select all that apply.
a. A+
b. B+
c. B-
d. O+
e. O-
f. AB+
c, e
A nurse is providing teaching for a client who has stage 2 HIV and is having difficulty
maintaining a normal weight. Which of the following statements by the client should
indicate to the nurse an understanding of the teaching?
a. I will choose to diet high in fat to help gain weight
b. I will be sure to eat 3 large meals a day
c. I will drink up to 1 liter of fluid a day
d. I will add high-protein foods to my diet
, D. high protein and high calorie is the best way to gain weight and maintain
health
· Which woman is at highest risk for cervical cancer?
o A 25-year-old woman who smokes and has multiple sexual partners
o A 40-year-old woman who had her first child at age 19 years and has been exposed to
HPV
o An 18-year-old woman who has just had her first sexual encounter
o An obese 30-year-old woman who has nutritional deficiencies and a family history of
cervical cancer
Answer: An obese 30-year-old woman who has nutritional deficiencies and a
family history of cervical cancer
· Rationale: Risk factors for cervical cancer include but are not limited to
smoking, multiple sexual partners, first child at an early age, exposure to HPV,
first sexual encounter at an early age, obesity, nutritional deficiencies, and a
family history of cervical cancer. All patients have risk factors, but the 40-year-
old woman has the most (three: obesity, nutritional deficiencies, and family
history)
The nurse is teaching the client with peripheral vascular disease. Which interventions
should the nurse discuss with the client? Select all that apply.
1.Wash your feet in antimicrobial soap.
2.Wear comfortable, well-fitting shoes
3.Cut your toenails in an arch.
4.Keep the area between the toes dry.
5.Use a heating pad when feet are cold.
