_____________Quiz____________?
A nurse in a telemetry unit is collecting data from a client who has a newly-inserted
permanent pacemaker. Which of the following findings should the nurse report to the
provider?
The client experiences hiccups when sitting.
The client's pulse rate is 5/min faster than the preset pacemaker rate.
There is the presence of a pacing spike before the P-wave on the ECG rhythm strip.
The dressing over the insertion site is dry and intact. -
Answer✓✓
The client experiences hiccups when sitting.
_____________Quiz____________?
Click to highlight the findings the nurse should report to the charge nurse immediately. To
deselect a finding, click on the finding again. -
Answer✓✓
• Perineal pad is saturated with blood, and large clots are present is correct. The presence
of vaginal bleeding and blood clots is a manifestation of vaginal hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
• Blood pressure 98/56 mm Hg is correct. Decreased
blood pressure is a manifestation of vaginal hemorrhage.
1
, Therefore, the nurse should report this finding to the charge nurse.
• Heart rate 102/min is correct, Tachycardia is a manifestation of vaginal hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
_____________Quiz____________?
A nurse is assisting with the care for a client who reports shortness of breath and has an
oxygen saturation
90%. Which of the following actions should the nurse take? -
Answer✓✓
Administer oxygen via nasal cannula
R: The nurse should administer oxygen via nasal cannula to a client who reports shortness
of breath and has an oxygen saturation below the expected reference range. The nurse
should continue to monitor the client and adjust the oxygen flow rate as needed.
_____________Quiz____________?
A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about
manifestations of impending death. Which of the following manifestations should the nurse
include? -
Answer✓✓
Incontinence of the bowel and bladder.
Rationale:The nurse should inform the caregiver that incontinence of the bowel and bladder
is a manifestation of impending death. Other manifestations include hypotension,
bradycardia, restlessness, and coolness of the skin.
_____________Quiz____________?
A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been
taking methimazole for 4 weeks. Which of the following statements by the client indicates a
therapeutic response to the medication? -
Answer✓✓
2
, "I have gained 3 lbs since my last appointment"
R: Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain
as an indication that the methimazole therapy has been effective
_____________Quiz____________?
A nurse is contributing to the plan of care for a client who is postoperative following a total
knee arthroplasty.
The client is using a continuous passive motion (CPM) machine. Which of the following
interventions should the nurse recommend for the plan of care? -
Answer✓✓
Keep a sheepskin pad between the client's extremity and the CPM machine.
R: The nurse should plan to keep a sheepskin pad between the dient's extremity and the
cOM madhune to protect the client's skin. The nurse should check the client's skin
condition frequendy wile the cient is using the CPM machine.
_____________Quiz____________?
A nurse is reinforcing teaching with a client about testicular self-examination. Which of the
following instructions should the nurse include in the teaching? -
Answer✓✓
"Perform testicular self-examination after taking a warm shower."
Rationale: The nurse should instruct the client to perform testicular self-examination after
taking a warm shower or bath. This causes relaxation of the scrotal skin, which allows for
better palpation of the testes.
_____________Quiz____________?
A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's
disease. Which of the following information should the nurse include in the teaching? -
Answer✓✓
Remind the client to avoid watching their feet when walking.
3
, R: The nurse should remind the client's caregivers to frequently remind the client to
maintain correct posture and prevent falls by not watching their feet when walking.
_____________Quiz____________?
A home health nurse is assisting with the care for a client who has COPD. The client
reports shortness of breath while eating, despite the use of home oxygen. Which of the
following recommendations should the nurse make? -
Answer✓✓
"Use a bronchodilator 30 minutes before your meal."
R: The dient should use a bronchodilator 30 min before meals to prevent shortness of
breath while eating.
_____________Quiz____________?
A nurse is assisting with the care of a client who has a newly inserted water-seal closed
chest tube. Which of the following findings should the nurse report to the provider? -
Answer✓✓
Chest drainage is greater than 70 mL/hr.
RAT: The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a
complication and should be reported to the provider. Water fluctuates in the water-seal
chamber.
Water should fluctuate in the water-seal chamber. The water rises and falls upon the client's
respiratory effort. Therefore, this finding does not need to be reported to the provider.
_____________Quiz____________?
A nurse is assisting with the care for a client who has a compound fracture of the femur and
was placed in balanced suspension skeletal traction 4 days ago. Which of the following
actions should the nurse take? -
Answer✓✓
Perform pin site care daily.
4
A nurse in a telemetry unit is collecting data from a client who has a newly-inserted
permanent pacemaker. Which of the following findings should the nurse report to the
provider?
The client experiences hiccups when sitting.
The client's pulse rate is 5/min faster than the preset pacemaker rate.
There is the presence of a pacing spike before the P-wave on the ECG rhythm strip.
The dressing over the insertion site is dry and intact. -
Answer✓✓
The client experiences hiccups when sitting.
_____________Quiz____________?
Click to highlight the findings the nurse should report to the charge nurse immediately. To
deselect a finding, click on the finding again. -
Answer✓✓
• Perineal pad is saturated with blood, and large clots are present is correct. The presence
of vaginal bleeding and blood clots is a manifestation of vaginal hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
• Blood pressure 98/56 mm Hg is correct. Decreased
blood pressure is a manifestation of vaginal hemorrhage.
1
, Therefore, the nurse should report this finding to the charge nurse.
• Heart rate 102/min is correct, Tachycardia is a manifestation of vaginal hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
_____________Quiz____________?
A nurse is assisting with the care for a client who reports shortness of breath and has an
oxygen saturation
90%. Which of the following actions should the nurse take? -
Answer✓✓
Administer oxygen via nasal cannula
R: The nurse should administer oxygen via nasal cannula to a client who reports shortness
of breath and has an oxygen saturation below the expected reference range. The nurse
should continue to monitor the client and adjust the oxygen flow rate as needed.
_____________Quiz____________?
A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about
manifestations of impending death. Which of the following manifestations should the nurse
include? -
Answer✓✓
Incontinence of the bowel and bladder.
Rationale:The nurse should inform the caregiver that incontinence of the bowel and bladder
is a manifestation of impending death. Other manifestations include hypotension,
bradycardia, restlessness, and coolness of the skin.
_____________Quiz____________?
A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been
taking methimazole for 4 weeks. Which of the following statements by the client indicates a
therapeutic response to the medication? -
Answer✓✓
2
, "I have gained 3 lbs since my last appointment"
R: Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain
as an indication that the methimazole therapy has been effective
_____________Quiz____________?
A nurse is contributing to the plan of care for a client who is postoperative following a total
knee arthroplasty.
The client is using a continuous passive motion (CPM) machine. Which of the following
interventions should the nurse recommend for the plan of care? -
Answer✓✓
Keep a sheepskin pad between the client's extremity and the CPM machine.
R: The nurse should plan to keep a sheepskin pad between the dient's extremity and the
cOM madhune to protect the client's skin. The nurse should check the client's skin
condition frequendy wile the cient is using the CPM machine.
_____________Quiz____________?
A nurse is reinforcing teaching with a client about testicular self-examination. Which of the
following instructions should the nurse include in the teaching? -
Answer✓✓
"Perform testicular self-examination after taking a warm shower."
Rationale: The nurse should instruct the client to perform testicular self-examination after
taking a warm shower or bath. This causes relaxation of the scrotal skin, which allows for
better palpation of the testes.
_____________Quiz____________?
A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's
disease. Which of the following information should the nurse include in the teaching? -
Answer✓✓
Remind the client to avoid watching their feet when walking.
3
, R: The nurse should remind the client's caregivers to frequently remind the client to
maintain correct posture and prevent falls by not watching their feet when walking.
_____________Quiz____________?
A home health nurse is assisting with the care for a client who has COPD. The client
reports shortness of breath while eating, despite the use of home oxygen. Which of the
following recommendations should the nurse make? -
Answer✓✓
"Use a bronchodilator 30 minutes before your meal."
R: The dient should use a bronchodilator 30 min before meals to prevent shortness of
breath while eating.
_____________Quiz____________?
A nurse is assisting with the care of a client who has a newly inserted water-seal closed
chest tube. Which of the following findings should the nurse report to the provider? -
Answer✓✓
Chest drainage is greater than 70 mL/hr.
RAT: The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a
complication and should be reported to the provider. Water fluctuates in the water-seal
chamber.
Water should fluctuate in the water-seal chamber. The water rises and falls upon the client's
respiratory effort. Therefore, this finding does not need to be reported to the provider.
_____________Quiz____________?
A nurse is assisting with the care for a client who has a compound fracture of the femur and
was placed in balanced suspension skeletal traction 4 days ago. Which of the following
actions should the nurse take? -
Answer✓✓
Perform pin site care daily.
4
