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Terms in this set (160)
The nurse is completing the admission B. Sluggish and unequal pupillary responses
assessment of a 3-year old who is
admitted with bacterial meningitis and
hydrocephalus. Which assessment
finding is evidence that the child is
experiencing increased intracranial
pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary
responses
C. Increased head circumference and
bulging fontanels
D. Blood pressure fluctuations and
syncope
, A client with acute pancreatitis is A. Abdominal pain decreases when lying supine
admitted with severe, piercing
abdominal pain and an elevated serum
amylase. Which additional information
is the client most likely to report to the
nurse?
A. Abdominal pain decreases when
lying supine
B. Pain lasts an hour and leaves the
abdomen tender
C. Right upper quadrant pain refers to
right scapula
D. Drinks alcohol until intoxicated at
least twice weekly.
A child newly diagnosed with sickle A. Instructions about how much fluid the child should
cell anemia (SCA) is being discharged drink daily
from the hospital. Which information is
most important for the nurse to provide
the parents prior to discharge?
A. Instructions about how much fluid
the child should drink daily.
B. Signs of addiction to opioid pain
medications
C. Information about non-
pharmaceutical pain relief measures
D. Referral for social services for the
child and family
To auscultate for a carotid bruit, the I placed the red dot on the base of the neck on the right
nurse places the stethoscope at what side
location. (Select the location on the
image with a red dot).
After receiving report on an inpatient D. The client with a bowel obstruction due to a
acute care unit, which client should the volvulus who is experiencing abdominal rigidity
nurse assess first?
A. The client with an obstruction of the
large intestine who is experiencing
abdominal distention
B. The client who had surgery
yesterday and is experiencing a
paralytic ileus with absent bowel
sounds
C. The client with a small bowel
obstruction who has a nasogastric tube
that is draining greenish fluid
D. The client with a bowel obstruction
due to a volvulus who is experiencing
abdominal rigidity
A teenager presents to the emergency D. Respiratory alkalosis
department with palpitations after
vaping at a party. The client is anxious,
fearful, and hyperventilating. The nurse
anticipates the client developing which
acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
A client with dyspnea is being admitted Fowlers
to the medical unit. To best prepare for
the client's arrival, the nurse should
ensure that the client's bed is in which
position?
A. Supine
B. supine; feet elevated higher than
head
C. supine; head elevated higher than
feet
D. Fowlers
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16
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Terms in this set (160)
The nurse is completing the admission B. Sluggish and unequal pupillary responses
assessment of a 3-year old who is
admitted with bacterial meningitis and
hydrocephalus. Which assessment
finding is evidence that the child is
experiencing increased intracranial
pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary
responses
C. Increased head circumference and
bulging fontanels
D. Blood pressure fluctuations and
syncope
, A client with acute pancreatitis is A. Abdominal pain decreases when lying supine
admitted with severe, piercing
abdominal pain and an elevated serum
amylase. Which additional information
is the client most likely to report to the
nurse?
A. Abdominal pain decreases when
lying supine
B. Pain lasts an hour and leaves the
abdomen tender
C. Right upper quadrant pain refers to
right scapula
D. Drinks alcohol until intoxicated at
least twice weekly.
A child newly diagnosed with sickle A. Instructions about how much fluid the child should
cell anemia (SCA) is being discharged drink daily
from the hospital. Which information is
most important for the nurse to provide
the parents prior to discharge?
A. Instructions about how much fluid
the child should drink daily.
B. Signs of addiction to opioid pain
medications
C. Information about non-
pharmaceutical pain relief measures
D. Referral for social services for the
child and family
To auscultate for a carotid bruit, the I placed the red dot on the base of the neck on the right
nurse places the stethoscope at what side
location. (Select the location on the
image with a red dot).
After receiving report on an inpatient D. The client with a bowel obstruction due to a
acute care unit, which client should the volvulus who is experiencing abdominal rigidity
nurse assess first?
A. The client with an obstruction of the
large intestine who is experiencing
abdominal distention
B. The client who had surgery
yesterday and is experiencing a
paralytic ileus with absent bowel
sounds
C. The client with a small bowel
obstruction who has a nasogastric tube
that is draining greenish fluid
D. The client with a bowel obstruction
due to a volvulus who is experiencing
abdominal rigidity
A teenager presents to the emergency D. Respiratory alkalosis
department with palpitations after
vaping at a party. The client is anxious,
fearful, and hyperventilating. The nurse
anticipates the client developing which
acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
A client with dyspnea is being admitted Fowlers
to the medical unit. To best prepare for
the client's arrival, the nurse should
ensure that the client's bed is in which
position?
A. Supine
B. supine; feet elevated higher than
head
C. supine; head elevated higher than
feet
D. Fowlers
