Verified 100% Correct
A client who is one week postoperative after an aortic valve replacement suddenly develops
severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and
cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which
action should the nurse take?
A. Elevate the legs and medicate for pain.
B. Apply firm pressure to the femoral artery.
C. Keep the client in bed in the supine position.
D. Encourage the client to exercise the leg. - C
A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he
thinks he may have been exposed. Which response should the nurse provide?
A. Cover the ticks with oil to suffocate and kill them to prevent transmission.
B. Look for early signs of a lesion that increases in size with a red border, clear center.
C. See a healthcare provider if nausea, vomiting, and joint pain occur after a tick bite.
D. Obtain early treatment with antiviral agents to prevent cardiac manifestations. - B
The nurse plans to suction a male client who has just undergone right pneumonectomy for
cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse
auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning
this client?
A. Suction for only 5 seconds since the client has only one lung and cannot hold his breath for
very long.
B. Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning.
C. Have another person available to hold the client's hands to prevent inadvertent removal of
the suction tube.
D. Suction deeply and vigorously to ensure that all secretions are removed in order to prevent
atelectasis. - B
, The nurse is preparing to administer a prescribed dose of acetylcysteine (Mucomyst) 600 mg
PO. The 10 ml vial is labeled "Mucomyst 20% solution (20 grams/100 ml)." What volume of
medication in milliliters should the nurse administer? (Enter numeric value only.) - 3mL
Which nurse follows a client from admission through discharge or resolution of illness and
coordinates the client's care between healthcare providers?
Case manager.
Nurse-manager.
Quality manager.
Discharge manager. - Case manager
The nurse is monitoring neurological vital signs for a male client who lost consciousness after
falling and hitting his head. Which assessment finding is the earliest and most sensitive
indication of altered cerebral function?
A. Unequal pupils.
B. Loss of central reflexes.
C. Inability to open the eyes.
D. Change in level of consciousness.
Submit - D
The school nurse is reviewing health risks associated with extracurricular activities of grade-
school children. Regular participation in which activity places the child at highest risk for
developing external otitis?
A. Batting practice at a batting cage.
B. Soccer practice at an outdoor field.
C. Swimming lessons in an indoor pool.
D. Roller skating at an indoor rink. - C
A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes
the perineum and sees the umbilical cord extruding from the introitus. In which position should
the nurse place the client?
A. Left supine with thighs flexed on her abdomen.