Question 1
The nurse is caring for a post-operative client who has a saline lock in place and very little
urine in the drainage bag. The client appears anxious and restless. The nurse notes that
the client's hands are cool and moist, and that the capillary refill is prolonged. Which
action should the nurse perform?
Offer the client a warm blanket.
Assess the client's breath sounds.
Administer IV fluids per protocol.
Review the client's medications.
CORRECT ANSWER
Administer IV fluids per protocol.
The client is showing signs of hypovolemic shock, a potential post-operative
complication. The nurse correctly treats this problem by infusing IV fluids per protocol.
Question 2
When performing percussion of the lungs, the nurse notes a dull sound in the left lower
chest. This finding may indicate the presence of which condition?
Pneumothorax.
1
@THE STUDY VAULT
,Pleural effusion.
Chronic bronchitis.
Emphysema.
CORRECT ANSWER
Pleural effusion.
Percussion is used to assess pulmonary resonance. A dull sound indicates the presence of
solid tissue, such as the liver in the right lower chest, or an abnormal accumulation of
fluid, such as an effusion.
Question 3
Which characteristic is typical of hypertensive crisis?
Clinical evidence of flatten jugular vein.
Development of a headache or blurred vision.
Diastolic blood pressure less than 110 mm Hg.
Elevated cardiac enzymes.
CORRECT ANSWER
Development of a headache or blurred vision.
2
@THE STUDY VAULT
, Hypertensive crisis involves elevated blood pressure that can cause organ damage if the
blood pressure is not brought down immediately. This condition rarely occurs, often is a
result of clients not taking their hypertensive medications as prescribed.
Question 4
The nurse is caring for a client with a fractured left hip. During the admission assessment,
the nurse notes petechiae and an increased heart rate. Which action should the nurse
perform next?
Observe the fracture site for ecchymosis.
Obtain the client's blood pressure.
Document the assessment findings.
Assess the client's breath sounds.
CORRECT ANSWER
Assess the client's breath sounds.
A client with a fractured hip is at an increased risk for fat embolism syndrome (FES). The
fat emboli can travel throughout the circulatory system and block capillaries (resulting in
petechiae) or small vessels supplying vital organs, including the lungs. The nurse should
assess the client's breath sounds to determine if emboli have traveled to the client's
lungs.
Question 5
While assessing a pediatric client with cerebral palsy, the nurse notes that the child feels
rigid and has significant arching of the back. Which action should the nurse take?
3
@THE STUDY VAULT
The nurse is caring for a post-operative client who has a saline lock in place and very little
urine in the drainage bag. The client appears anxious and restless. The nurse notes that
the client's hands are cool and moist, and that the capillary refill is prolonged. Which
action should the nurse perform?
Offer the client a warm blanket.
Assess the client's breath sounds.
Administer IV fluids per protocol.
Review the client's medications.
CORRECT ANSWER
Administer IV fluids per protocol.
The client is showing signs of hypovolemic shock, a potential post-operative
complication. The nurse correctly treats this problem by infusing IV fluids per protocol.
Question 2
When performing percussion of the lungs, the nurse notes a dull sound in the left lower
chest. This finding may indicate the presence of which condition?
Pneumothorax.
1
@THE STUDY VAULT
,Pleural effusion.
Chronic bronchitis.
Emphysema.
CORRECT ANSWER
Pleural effusion.
Percussion is used to assess pulmonary resonance. A dull sound indicates the presence of
solid tissue, such as the liver in the right lower chest, or an abnormal accumulation of
fluid, such as an effusion.
Question 3
Which characteristic is typical of hypertensive crisis?
Clinical evidence of flatten jugular vein.
Development of a headache or blurred vision.
Diastolic blood pressure less than 110 mm Hg.
Elevated cardiac enzymes.
CORRECT ANSWER
Development of a headache or blurred vision.
2
@THE STUDY VAULT
, Hypertensive crisis involves elevated blood pressure that can cause organ damage if the
blood pressure is not brought down immediately. This condition rarely occurs, often is a
result of clients not taking their hypertensive medications as prescribed.
Question 4
The nurse is caring for a client with a fractured left hip. During the admission assessment,
the nurse notes petechiae and an increased heart rate. Which action should the nurse
perform next?
Observe the fracture site for ecchymosis.
Obtain the client's blood pressure.
Document the assessment findings.
Assess the client's breath sounds.
CORRECT ANSWER
Assess the client's breath sounds.
A client with a fractured hip is at an increased risk for fat embolism syndrome (FES). The
fat emboli can travel throughout the circulatory system and block capillaries (resulting in
petechiae) or small vessels supplying vital organs, including the lungs. The nurse should
assess the client's breath sounds to determine if emboli have traveled to the client's
lungs.
Question 5
While assessing a pediatric client with cerebral palsy, the nurse notes that the child feels
rigid and has significant arching of the back. Which action should the nurse take?
3
@THE STUDY VAULT
