Term 1 of 98
408. A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his
blood pressure is elevated. Based on this finding, this client is at a greatest risk for which
pathophysiological condition?
- Pulmonary hypertension
- Left ventricular hypertrophy
- Renal failure
- Stroke
,Term 2 of 98
491. The healthcare provider prescribes heparin protocol at18 units/kg/hr for a client with a
possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled,
heparinsodium 25,000 units in 5% dextrose 250 ml. the nurse should program the pump to deliver
how many ml/hr? (Enter numeric value only. If rounding is requiring round to the nearest whole
number.)
a- Long distance runner since high school
Rationale: Osteoarthritis is a degenerative joint disease of the cause by traumatic or
repetitive stress to weight-bearing joint such as high impact sport like running.
a- headache, photophobia, and nuchal rigidity
Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal
infection, so this client should immediately be referred to the health care provider. AC D do
not have priority of B
12
Rationale: 144/2.2= 65kg 18units/kg/hr 65 kg x 18units/kg/hr= 1170 units/hr 25000 units
heparin/250 ml of D5W = 100 units heparin per ml of solution Formula D/H x A = X
a- Encourage use of analgesics before position change
Rationale: Controlling the amount of pain prior to activity with the use of analgesics (A)
enhances client‟s....
Term 3 of 98
447. A client who had an open cholecystectomy two weeks ago comes to the emergency
department with complaints of nausea, abdominal distention, and pain. Which assessment should
the nurse implement?
- Auscultate all quadrant of the abdomen
- Perform a digital rectal exam
- Palpate the liver and spleen
- Obtain a hemoccult of the client‟s stool
,Term 4 of 98
465. During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and
initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse
implement?
a- Instruct the client to keep the left leg straight
b- Keep the head of bed at 60-degree angle
c- Observe the insertion site for a hematoma
d- Manually flush the arterial sheath hourly
e- Circle first noted drainage on the dressing
a- Contact the regional organ procurement agency
Rationale: First the organ procurement agencies should be contacted because they are
trained to work with... procurement process. The procurement agency is responsible for
calling a care conference (B), disc...organs are eligible for procurement (C), and specifying
when to discontinue nutrition and hydration
a- Instruct the client to keep the left leg straight
c- Observe the insertion site for a hematoma
e- Circle first noted drainage on the dressing
a- Discuss the importance of continuing the usual at-home activities
Rationale: Week-end pass are schedules to help the client ease back into the family‟s
routine, so the client can back to normal activities.
a- History of hypertension
e- Family heath history
Rationale: Based on the client‟s family history and medication for management of
hypertension, the nurse should further explore these risk for ischemic heart disease.
, Term 5 of 98
455. A nurse is conducting a physical assessment of a young adult. Which information provides
the best indication of the individual nutritional status?
- A 24-hour diet history
- History of a recent weight loss
- Status of current petite
- Condition of hair, nails, and skin
Term 6 of 98
487. 345- During a cardiopulmonary resuscitation of an intubated client, the nurse detects a
palpable pulse throughout the two minutes‟ cycle chest compression and absent breath sounds
over the left lung. What action should the nurse implement?
- Instruct the compressor to stop chest compression.
- Advise ventilator to increase bag-mask ventilation rate.
- Plan to suction endotracheal tube at two-minute check.
- Prepare for the endotracheal tube to be repositioned
Term 7 of 98
466. A client whose wrists are sutured from a recent suicide attempt is been transferred from a
medical unit. Which nursing diagnosis is of the highest priority?
- Risk for self-directed violence related to impulsive actions
- Risk for violence related to feeling of guilt and failure
- Low self-esteem related to feeling of loss of control
- Ineffective coping related to violent actions towards self
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