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female client is recently diagnosed with Sarciodosis. The client tells the registered nurse (RN)
that she does not understand why she has this. When teaching about the occurrence of
sarcoidosis, the RN should include that sarcoidosis most commonly occurs with which ethnic
group of women?
A. African American women
B. Caucasian women
C. Asian women
D. Hispanic women
A
Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium,
so withholding the medication (A) until the healthcare provider is notified should be initiated to
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maintain client safety. If the symptoms continue and are not addressed immediately, then (B, C,
and D) may place the client in imminent danger. – ANS
:A client who uses ipratropium reports having nausea, blurred vision, headaches, and insomnia
after using the inhaler. Which action should the registered nurse (RN) implement first?
A. Withhold medication and report symptoms and vital signs to healthcare provider.
B. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes.
C. Reassure client that the ipratropium given will alleviate the symptoms.
D. Delay administration of ipratropium until next maintenance medication is scheduled.
B
Troponin (B) is the most sensitive and specific test for myocardial damage. Troponin elevation is
more specific than CK-MB (A). (C) can be elevated when there is skeletal muscle damage. (D)
can be elevated nonspecifically and create false positives, so is not a reliable choice. - ANS :A
client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for
Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN)
anticipate to be elevated if the client experienced myocardial damage?
A. Creatine Kinase (CK-MB)
B. Serum troponin
C. Myoglobin
D. Ischemia modified albumin
D
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A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream
and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be
reported to the healthcare provider immediately. (A, B, and C) are expected findings after a fall
and do not require immediate notification of a healthcare provider. - ANS :
The registered nurse (RN) is caring for an older client who recently experienced a fractured
pelvis from a fall. Which assessment finding is most important for the RN to report to the
healthcare provider?
A. Lower back pain
B. Headache of 7 on scale of 1 to 10
C. Blood pressure of 140/98
D. Dypsnea
A
Maintaining hemodynamic stability in a client with esophageal varices can precipitate a life-
threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority
is assessing and monitoring infusions of IV fluids and any replacement blood products (A). The
healthcare provider should be present during (B and D) in the event the client's esophageal
varies rupture and bleed profusely. Bedrest (C) is not a priority at this time. - ANS
:While caring for a client who has esophageal varices, which nursing intervention is most
important for the registered nurse (RN) to implement?
A. Monitor infusing IV fluids and any replacement blood products
B. Prepare for esophagogastroduodenoscopy (EGD)
C. Maintain a client on strict bedrest
D. Insert a nasogastric tube (NGT) for intermittent suction
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D
Stiffness in joints is an early sign of contractures and muscle atrophy (D) related to inactivity and
immobility. Decreased pedal pulses (A), upper extremity (B) and a loss of appetite (C) are not
directly related to immobility. - ANS :
The registered nurse (RN) is caring for an older client who has been bedridden for two weeks.
Which assessment findings indicate to the RN that the client is developing a complication
related to immobility?
A. Decreased pedal pulses
B. Edema in upper extremities
C. Loss of appetite for food
D. Stiffness in right ankle joint
B
The first priority of a successful physical assessment is establishing rapport with the client.
Having the client sign the admission forms, taking his vital signs, and obtaining equipment are
also important but aren't the nurse's first priority in most cases. - ANS
:An 82-year-old client is admitted with pneumonia. Which of the following actions should be the
nurse's first priority as she performs this client's admission assessment?
A. Having the client sign the admission forms
B. Establishing rapport with the client
C. Obtaining the necessary equipment
D. Taking the client's vital signs
A
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