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A young female client with seven children is having frequent
morning headaches, dizziness, and blurred vision. Her blood
pressure (BP) is 168/104 mmHg. The client reports that her
husband recently lost his job and she is not sleeping well. After
administering a STAT dose of an antihypertensive IV
medication, which intervention is most important for the nurse
to implement?
A. Measure urine output hourly to assess for rental perfusion
B. Request a prescription for pain medication
C. Use an automated BP machine to monitor for hypotension
D. Provide a quiet environment with low lighting - ANSWER -C.
Use an automated BP machine to monitor for hypotension
The wife of a client with Parkinson's disease expresses
concern because her
husband has lost so much weight. Which teaching is best
for the nurse to
provide?
,A. Invite friends over regularly to share in meal times
B. Encourage the client to drink clear liquids between meals
C. Coach the client to make an intentional effort to swallow
D. Talk to the healthcare provider about prescribing an appetite
stimulant - ANSWER -A. Invite friends over regularly to share
in meal times
A client who was discharged 8 months ago with cirrhosis and
ascites is admitted with anorexia and recent hemoptysis. The
client is drowsy but responds to verbal stimuli. The nurse
programs a blood pressure monitor to take readings every 15
minutes,. Which assessment should the nurse implement first?
A. Evaluate distal capillary refill for delayed perfusion
B. Check the extremities for bruising and petechiae
C. Examine the pretibial regions for pitting edema
D. Palpate the abdomen for tenderness and rigidity - ANSWER -
D. Palpate the abdomen for tenderness and rigidity
A client with urolithiasis is preparing for discharge after
lithotripsy. Which intervention should the nurse include in the
client's postoperative discharge instructions?
A. Report when hematuria becomes pink tinged
B. Use incentive spirometer
C. Restrict physical activities
D. Monitor urinary stream for decrease in output - ANSWER -D.
Monitor urinary stream for decrease in output
,A fair-skinned female client who is an avid runner is diagnosed
with malignant melanoma, which is located on the lateral
surface of the lower leg. After wide margin resection, the nurse
provides discharge teaching. I t is most important for the nurse
to emphasize the need to observe for changes in which
characteristic?
A. Elasticity of the skin
B. Appearance of any moles
C. Muscle aches and pains
D. Pigmentation of the skin - ANSWER -B. Appearance of any
moles
A healthcare worker with no known exposure to tuberculosis
has received a Mantoux tuberculosis skin test. The nurse's
assessment of the test after 62 hours indicates 5 mm of
erythema without induration. What is the best initial nursing
action? - ANSWER -Document negative results in the client's
medical record
The nurse is teaching the importance of an exercise regime that
includes walking daily for a group of clients with asthma,
chronic bronchitis, and emphysema at a pulmonary
rehabilitation clinic. Which rationale should the nurse include
when motivating the clients? - ANSWER -Daily exercise and
walking enhances cardiovascular fitness
The nurse reviews the laboratory results of a client during an
annual physical
, examination and identifies a positive guaiac test of stool.
Which additional
serum laboratory test result should the
nurse review?
A.
Glucose
B.
Platelet
count
C. White
blood cell
count
D. Amylase -
ANSWER -B.
Platelet
count
A client with hypothyroidism reports difficulty falling asleep
because of feelings
of depression. Which action should the nurse implement? -
ANSWER -Review
most recent thyroid function
test results
An older client arrives at the outpatient eye surgery clinic for a
right cataract extraction and lens implant. During the immediate
postoperative period, which intervention should the nurse
implement?