A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone
ointment. The nurse should assess the client to monitor for which of the following adverse
effects? - ANSWER Thinning of the skin.
Only apply the ointment to dry patches of the skin to avoid atrophy.
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse identify as a manifestation of left-sided heart failure? -
ANSWER Frothy sputum
Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-
threatening. Therefore, the nurse should notify the provider immediately.
A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of
the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2
85 mm Hg. Which of thefollowing acid-base imbalances should the nurse identify that the
client is experiencing? - ANSWER Respiratory alkalosis
- The pH is alkaline (increased)
- PCO2 is decreased representing alveolar hyperventilation & resultant respiratory alkalosis
A nurse is assessing a client who has Cushing's syndrome. Which of the following findings
should the nurse expect? - ANSWER Osteoporosis
1
,Bone become thinner as a result of mineral loss & nitrogen depletion.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should
identify which of the following lesion characteristics on the client's skin? - ANSWER A
pearly, waxy nodule.
- Basal cell carcinoma has a nodular lesion with well defined borders & pearly or waxy
appearance resulting from overexposure to the sun. especially on the face, head, and neck.
-A client who has melanoma has a lesion with irregular borders and variegated colors of red,
white, and blue, most often on the upper back or lower legs.
-A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion with a
ulcerated center, resulting from sun exposure, chronic irritation, burns, or irradiation to the
skin.
A nurse in an emergency department is assessing a client who is overusing prescribed
diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings
should the nurse expect? - ANSWER LOW URINE SPECFIC GRAVITY.
-A client who has hyponatremia as a result of diuretic overuse has a low urine specific
gravity. The increased excretion of water alters the ratio of particulate matter, which affects
the specific gravity.
A home health nurse is assisting a client with planning care for a family member who has
Alzheimer's disease. Which of the following instructions should the nurse include? -
ANSWER Remove clutter from rooms and hallways
- This allows the client is able to walk without the risk of falling or tripping over objects.
Later in the disease, the client can experience seizures, so cluttered areas could be a risk to
the client
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS).
Which of the following findings should the nurse identify as a manifestation of this
syndrome? - ANSWER REFRACTORY HYPOXEMIA
2
, - A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not
improve with oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a
manifestation of ARDS.
An emergency room nurse is assessing a client who has asthma and difficulty breathing.
Which of the following findings should indicate to the nurse that the client is experiencing
status asthmaticus? - ANSWER USE OF ASSCESSORY MUSCLES.
- A client who has status asthmaticus uses accessory muscles to help facilitate breathing,
which is a manifestation of a severe airflow obstruction. The situation is life-threatening and
the nurse should intervene immediately with strong systemic bronchodilators, epinephrine,
corticosteroids, and oxygen.
A nurse is teaching a client who has a new prescription for PHENYTOIN to treat a seizure
disorder. Which of the following adverse effects should the nurse instruct the client to report
IMMEDIATELY to the provider? - ANSWER SKIN RASH.
- the nurse should determine that the priority finding is a rash, which can have a measles-
like appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The
client should report this finding to the provider immediately.
A nurse is monitoring a client following a LUMBAR LAMINECTOMY. The client has a drain and
indwelling urinary catheter. The nurse should identify which of the following findings as an
indication of a COMPLICATION of the surgery? - ANSWER CLEAR DRAINAGE OF
DRESSINGS
- This is an indication of a cerebral spinal leak
A nurse is assessing a client who has RIGHT-SIDED HEART FAILURE. Which of the following
findings should the nurse identify as a manifestation of RIGHT- SIDED HEART FAILURE? -
ANSWER INCREASED ABDOMINAL GIRTH
3
ointment. The nurse should assess the client to monitor for which of the following adverse
effects? - ANSWER Thinning of the skin.
Only apply the ointment to dry patches of the skin to avoid atrophy.
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse identify as a manifestation of left-sided heart failure? -
ANSWER Frothy sputum
Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-
threatening. Therefore, the nurse should notify the provider immediately.
A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of
the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2
85 mm Hg. Which of thefollowing acid-base imbalances should the nurse identify that the
client is experiencing? - ANSWER Respiratory alkalosis
- The pH is alkaline (increased)
- PCO2 is decreased representing alveolar hyperventilation & resultant respiratory alkalosis
A nurse is assessing a client who has Cushing's syndrome. Which of the following findings
should the nurse expect? - ANSWER Osteoporosis
1
,Bone become thinner as a result of mineral loss & nitrogen depletion.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should
identify which of the following lesion characteristics on the client's skin? - ANSWER A
pearly, waxy nodule.
- Basal cell carcinoma has a nodular lesion with well defined borders & pearly or waxy
appearance resulting from overexposure to the sun. especially on the face, head, and neck.
-A client who has melanoma has a lesion with irregular borders and variegated colors of red,
white, and blue, most often on the upper back or lower legs.
-A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion with a
ulcerated center, resulting from sun exposure, chronic irritation, burns, or irradiation to the
skin.
A nurse in an emergency department is assessing a client who is overusing prescribed
diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings
should the nurse expect? - ANSWER LOW URINE SPECFIC GRAVITY.
-A client who has hyponatremia as a result of diuretic overuse has a low urine specific
gravity. The increased excretion of water alters the ratio of particulate matter, which affects
the specific gravity.
A home health nurse is assisting a client with planning care for a family member who has
Alzheimer's disease. Which of the following instructions should the nurse include? -
ANSWER Remove clutter from rooms and hallways
- This allows the client is able to walk without the risk of falling or tripping over objects.
Later in the disease, the client can experience seizures, so cluttered areas could be a risk to
the client
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS).
Which of the following findings should the nurse identify as a manifestation of this
syndrome? - ANSWER REFRACTORY HYPOXEMIA
2
, - A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not
improve with oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a
manifestation of ARDS.
An emergency room nurse is assessing a client who has asthma and difficulty breathing.
Which of the following findings should indicate to the nurse that the client is experiencing
status asthmaticus? - ANSWER USE OF ASSCESSORY MUSCLES.
- A client who has status asthmaticus uses accessory muscles to help facilitate breathing,
which is a manifestation of a severe airflow obstruction. The situation is life-threatening and
the nurse should intervene immediately with strong systemic bronchodilators, epinephrine,
corticosteroids, and oxygen.
A nurse is teaching a client who has a new prescription for PHENYTOIN to treat a seizure
disorder. Which of the following adverse effects should the nurse instruct the client to report
IMMEDIATELY to the provider? - ANSWER SKIN RASH.
- the nurse should determine that the priority finding is a rash, which can have a measles-
like appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The
client should report this finding to the provider immediately.
A nurse is monitoring a client following a LUMBAR LAMINECTOMY. The client has a drain and
indwelling urinary catheter. The nurse should identify which of the following findings as an
indication of a COMPLICATION of the surgery? - ANSWER CLEAR DRAINAGE OF
DRESSINGS
- This is an indication of a cerebral spinal leak
A nurse is assessing a client who has RIGHT-SIDED HEART FAILURE. Which of the following
findings should the nurse identify as a manifestation of RIGHT- SIDED HEART FAILURE? -
ANSWER INCREASED ABDOMINAL GIRTH
3
