good health overall?
A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC)
counts.
B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels.
C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria.
D. Serum electrolytes reveal a decreased sodium level and increased potassium level.
C
Rationale: In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or
subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as
a result of incomplete bladder emptying. Laboratory findings in options A, B, and D are not considered to be
normal findings in an older adult.
The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What
assessment data should the nurse collect immediately?
A. Reactivity of deep tendon reflexes, comparing upper with lower extremities
B. Vital sign readings, excluding blood pressure if needed equipment is unavailable
C. Memory of events that occurred before and after the blow to the head
D. Ability to open the eyes spontaneously before any tactile stimuli are given
D
Rationale: The level of consciousness (LOC) should be established immediately when a head injury has
occurred. Spontaneous eye opening is a simple measure of alertness that indicates that arousal mechanisms
are intact. Option A is not the best indicator of LOC. Although option B is important, vital signs are not the
best indicators of LOC and can be evaluated after the client's LOC has been determined. Option C can be
assessed after LOC has been established by assessing eye opening.
A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which
action should the nurse implement first?
A. Support the client to a sitting position.
B. Ask the client to walk slowly back to the room.
C. Administer a sublingual nitroglycerin tablet.
D. Provide oxygen via nasal cannula.
A
Rationale: The nurse should safely assist the client to a resting position and then perform options C and D.
The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial
muscle. After these interventions are implemented, the client can be escorted back to the room via
wheelchair or stretcher.
We have an expert-written solution to this problem!
In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes
,the absence of a thrill or bruit at the shunt site. What action should the nurse take?
A. Advise the client that the shunt is intact and ready for dialysis as scheduled.
B. Encourage the client to keep the shunt site elevated above the level of the heart.
,C. Notify Bthe Bhealth Bcare Bprovider Bof Bthe Bfindings Bimmediately.
D. Flush Bthe Bsite Bat Bleast Bonce Bwith Ba Bheparinized Bsaline
Bsolution. BC
Rationale: BAbsence Bof Ba Bthrill Bor Bbruit Bindicates Bthat Bthe Bshunt Bmay Bbe Bobstructed. BThe Bnurse Bshould
Bnotify Bthe Bhealth Bcare Bprovider Bso Bthat Bintervention Bcan Bbe Binitiated Bto Brestore Bfunction Bof Bthe Bshunt. BOption
BA Bis Bincorrect. BOption BB Bwill Bnot Bresolve Bthe Bobstruction. BAn BAV Bshunt Bis Binternal Band Bcannot Bbe Bflushed
Bwithout Baccess Busing Bspecial Bneedles.
We Bhave Ban Bexpert-written Bsolution Bto Bthis Bproblem!
The Bnurse Binitiates Bneurologic Bchecks Bfor Ba Bclient Bwho Bis Bat Brisk Bfor Bneurologic Bcompromise. BWhich
Bmanifestation Btypically Bprovides Bthe Bfirst Bindication Bof Baltered Bneurologic Bfunction?
A. Change Bin Blevel Bof Bconsciousness
B. Increasing Bmuscular Bweakness
C. Changes Bin Bpupil Bsize Bbilaterally
D. Progressive Bnuchal Brigidity
BA
Rationale: BA Bdecrease Bor Bchange Bin Bthe Blevel Bof Bconsciousness Bis Busually Bthe Bfirst Bindication Bof Bneurologic
Bdeterioration. BOptions BB Band BC Bmay Balso Boccur Bbut Bare Bmuch Bless Blikely Bto Bbe Bthe Bfirst Bsign Bof Bneurologic
Bcompromise. BOption BD Bis Boften Ba Bsign Bof Bmeningitis.
What Bis Bthe Bmost Bimportant Bnursing Bpriority Bfor Ba Bclient Bwho Bhas Bbeen Badmitted Bfor Ba Bpossible Bkidney Bstone?
A. Reducing Bdairy Bproducts Bin Bthe Bdiet
B. Straining Ball Burine
C. Measuring Bintake Band Boutput
D. Increasing Bfluid Bintake
BB
Rationale: BStraining Ball Burine Bis Bthe Bmost Bimportant Bnursing Baction Bto Btake Bin Bthis Bcase. BEncouraging Bfluid
Bintake Bis Bimportant Bfor Bany Bclient Bwho Bmay Bhave Ba Bkidney Bstone, Bbut Bit Bis Beven Bmore Bimportant Bto Bstrain
Ball Burine. BStraining Burine Bwill Benable Bthe Bnurse Bto Bdetermine Bwhen Bthe Bkidney Bstone Bhas Bbeen Bpassed Band
Bmay Bprevent Bthe Bneed Bfor Bsurgery. BOption BC Bis Bnot Bthe Bhighest Bpriority Baction. BOption BA Bis Busually Bnot
Brecommended Buntil Bthe Bstone Bis Bobtained Band Bthe Bcontent Bof Bthe Bstone Bis Bdetermined. BEven Bthen, Bdietary
Brestrictions Bare Bcontroversial.
We Bhave Ban Bexpert-written Bsolution Bto Bthis Bproblem!
During Bthe Bshift Breport, Bthe Bcharge Bnurse Binforms Ba Bnurse Bthat Bshe Bhas Bbeen Bassigned Bto Banother Bunit
Bfor Bthe Bday. BThe Bnurse Bbegins Bto Bsigh Bdeeply Band Btosses Babout Bher Bbelongings Bas Bshe Bprepares Bto
Bleave, Bmaking Bit Bknown Bthat Bshe Bis Bvery Bunhappy Babout Bbeing Bfloated Bto Bthe Bother Bunit. BWhat Bis Bthe
Bbest Bimmediate Baction Bfor Bthe Bcharge Bnurse Bto Btake?
A. Continue Bwith Bthe Bshift Breport Band Btalk Bto Bthe Bnurse Babout Bthe Bincident Bat Ba Blater Btime.
B. Ask Bthe Bnurse Bto Bcall Bthe Bhouse Bsupervisor Bto Bsee Bif Bshe Bmust Bbe Breassigned.
C. Stop Bthe Bshift Breport Band Bremind Bthe Bnurse Bthat Ball Bstaff Bare Bfloated Bequally.
D. Inform Bthe Bnurse Bthat Bher Bbehavior Bis Bdisruptive Bto Bthe Brest Bof Bthe
Bstaff. BA
Rationale: BContinuing Bwith Bthe Bshift Breport Bis Bthe Bbest Bimmediate Baction Bbecause Bit Ballows Bthe Bnurse Bwho
Bwas Bfloated Bsome Bcooling Boff Btime. BAt Ba Blater Btime B(after Bthe Bnurse Bhas Bcooled Boff) Bthe Bcharge Bnurse
Bshould Bdiscuss Bthe Bconduct Bof Bthe Bnurse Bin Bprivate. BOption BB Bencourages Bthe Bnurse Bto Bshirk Bthe Bfloat
Bassignment. BOption BC Bis Bdisruptive. BReprimanding Bthe Bnurse Bin Bfront Bof Bthe Bstaff Bwould Bincrease Bthe
Bnurse's Bhostility, Bso Bthe Bnurse Bshould Bbe Bcounseled Bin Bprivate.
When Beducating Ba Bclient Bafter Ba Btotal Blaryngectomy, Bwhich Binstruction Bwould Bbe Bmost Bimportant Bfor Bthe Bnurse
Bto Binclude Bin Bthe Bdischarge Bteaching?
, A. Recommend Bthat Bthe Bclient Bcarry Bsuction Bequipment Bat Ball Btimes.
B. Instruct Bthe Bclient Bto Bhave Bwriting Bmaterials Bwith Bhim Bat Ball Btimes.
C. Tell Bthe Bclient Bto Bcarry Ba Bmedical Balert Bcard Bthat Bexplains Bhis Bcondition.
D. Caution Bthe Bclient Bnot Bto Btravel Boutside Bthe BUnited BStates
Balone. BC
Rationale: BNeck Bbreathers Bcarry Ba Bmedical Balert Bcard Bthat Bnotifies Bhealth Bcare Bpersonnel Bof Bthe Bneed Bto
Buse Bmouth Bto Bstoma Bbreathing Bin Bthe Bevent Bof Ba Bcardiac Barrest Bin Bthis Bclient. BMouth Bto Bmouth Bresuscitation
Bwill Bnot Bestablish Ba Bpatent Bairway. BOptions BA Band BD Bare Bnot Bnecessary. BThere Bare Bmany Balternative
Bmeans Bof Bcommunication Bfor Bclients Bwho Bhave Bhad Ba Blaryngectomy; Bdependence Bon Bwriting Bmessages Bis
Bprobably Bthe Bleast Beffective.
The Bnurse Breceives Bthe Bclient's Bnext Bscheduled Bbag Bof BTPN Blabeled Bwith Bthe Badditive BNPH Binsulin. BWhich
Baction Bshould Bthe Bnurse Bimplement?
A. Hang Bthe Bsolution Bat Bthe Bcurrent Brate.
B. Refrigerate Bthe Bsolution Buntil Bneeded.
C. Prepare Bthe Bsolution Bwith Bnew Btubing.
D. Return Bthe Bsolution Bto Bthe
Bpharmacy. BD
Rationale: BOnly Bregular Binsulin Bis Badministered Bby Bthe BIV Broute, Bso Bthe BTPN Bsolution Bcontaining BNPH
Binsulin Bshould Bbe Breturned Bto Bthe Bpharmacy. BOptions BA, BB, Band BC Bare Bnot Bindicated Bbecause Bthe
Bsolution Bshould Bnot Bbe Badministered.
Previous
Play
BNe
xt
Rewind B10 Bseconds
B Move Bforward B10
Bseconds BUnmute
Full Bscreen
A Bpostoperative Bclient Breceives Ba BSchedule BII Bopioid Banalgesic Bfor Bpain. BWhich Bassessment Bfinding
Brequires Bthe Bmost Bimmediate Bintervention Bby Bthe Bnurse?
A. Hypoactive Bbowel Bsounds Bwith Babdominal Bdistention
B. Client Breports Bcontinued Bpain Bof B8 Bon Ba B10-point Bscale
C. Respiratory Brate Bof B12 Bbreaths/min, Bwith BO2 Bsaturation Bof B85%
D. Client Breports Bnausea Bafter Breceiving Bthe
Bmedication BC
Rationale: BAdministration Bof Ba BSchedule BII Bopioid Banalgesic Bcan Bresult Bin Brespiratory Bdepression, Bwhich
Brequires Bimmediate Bintervention Bby Bthe Bnurse Bto Bprevent Brespiratory Barrest. BOptions BA, BB, Band BD Brequire
Baction Bby Bthe Bnurse Bbut Bare Bof Bless Bpriority Bthan Boption BC.
A Bclient Bis Bplaced Bon Ba Bmechanical Bventilator Bfollowing Ba Bcerebral Bhemorrhage, Band Bvecuronium Bbromide,
B0.04 Bmg/kg Bevery B12 Bhours BIV, Bis Bprescribed. BWhat Bis Bthe Bpriority Bnursing Bdiagnosis Bfor Bthis Bclient?
A. Impaired Bcommunication Brelated Bto Bparalysis Bof Bskeletal Bmuscles
B. High Brisk Bfor Binfection Brelated Bto Bincreased Bintracranial Bpressure
C. Potential Bfor Binjury Brelated Bto Bimpaired Blung Bexpansion
D. Social Bisolation Brelated Bto Binability Bto
Bcommunicate BA
Rationale:To Bincrease Bthe Bclient's Btolerance Bof Bendotracheal Bintubation Band/or Bmechanical Bventilation, Ba
Bskeletal Bmuscle Brelaxant Bsuch Bas Bvecuronium Bis Busually Bprescribed. BOption BA Bis Ba Bserious Boutcome
Bbecause Bthe Bclient Bcannot Bcommunicate Bhis Bor Bher Bneeds. BAlthough Bthis Bclient Bmight Balso Bexperience
Boption BD, Bit Bis Bnot Ba Bpriority Bwhen Bcompared Bwith Boption BA. BInfection Bis Bnot Brelated Bto Bincreased
Bintracranial Bpressure. BThe Brespirator Bwill Bensure Bthat Bthe Blungs Bare Bexpanded, Bso Boption BC Bis Bincorrect.