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ANSWERS
A client displays signs associated with a possible ruptured aortic
aneurysm. What is the priority nursing intervention? Correct Answers
Prepare the client for surgical intervention
A nurse is preparing a client for cardiac catheterization. What is the
nurse's priority assessment? Correct Answers Known allergies
A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is
scheduled to return from the post-anesthesia care unit. Which staff
member should receive this client? Correct Answers Registered nurse
with one year of experience
The nurse is monitoring a client, who is six hours post embolectomy, for
an acute arterial occlusion of the left leg. When a Doppler ultrasound
fails to detect a pedal pulse, the nurse notifies the surgeon who requests
that the client be prepared for immediate surgery. The client refuses to
consider additional surgery. What is the nurse's initial intervention?
Correct Answers Notify the provider immediately
A nurse has been assigned to four clients. Which client should the nurse
see first? Correct Answers A client with hemophilia who is receiving
acetylsalicylic acid (ASA) for joint pain
The nurse is making assignments for the next shift. Which client can be
assigned to a licensed practical nurse/licensed vocational nurse
,(LPN/LVN)? Select all that apply. Correct Answers A client who needs
assistance with colostomy irrigation
A client who is receiving glargine subcutaneously
The nurse is examining charts to identify clients at risk for developing
multiple myeloma. Which client is most at risk? Correct Answers a 60-
year-old Black man
Multiple myeloma is more common in middle-aged and older adult
clients. The median age at diagnosis is 60 years. It is twice as common
in Black clients as it is in White clients, and it occurs most often in
Black men.
A child is admitted to the pediatric unit with an unknown mass in her
lower left abdomen. Which is the nurse's priority action? Correct
Answers Place a "do not palpate abdomen" sign over the child's bed
Which client is most at risk for developing acute lymphocytic leukemia?
Correct Answers A 4-year-old white female
Acute lymphocytic leukemia is most common in young children and in
adults age 65 and older. It's also more common in whites than in blacks
or Asians.
A nurse, working in a rural county's public health department, has been
alerted that there is an outbreak of tuberculosis (TB) in the area. Which
, client is at highest risk for developing TB? Correct Answers A 43-year-
old homeless man with a history of alcoholism
A 24-year-old client comes into the clinic reporting sudden-onset, right-
sided chest pain and shortness of breath. While assessing the client, the
nurse determines that the most important intervention is to: Correct
Answers auscultate the breath sounds.
Because this client is short of breath, listening to breath sounds will
allow the nurse to obtain information to support care decisions and
report information that will help identify the problem. Breath sounds
may be decreased, abnormal or absent when a client is short of breath.
The client may need a chest X-ray and an ECG, but a health care
provider must order these tests. Unless a cardiac source for the client's
pain is identified, an echocardiogram won't be necessary.
A client with a pulmonary embolism is experiencing chest pain and
apprehension. What is the nurse's priority intervention? Correct Answers
Administering ordered analgesic
The nurse is planning interventions for a client who is having an acute
gout attack. What is the priority nursing intervention for this client?
Correct Answers Administer prescribed analgesics
The nurse is caring for a client admitted with Addisonian crisis. Which
outcome is the priority? Correct Answers Preventing irreversible shock