Nurse is caring for a client with diabetes insipidus (DI). which data warrants the most
immediate interventions by the nurse?
A. serum sodium of 185 mEq/L (185mmol/L)
B. Dry skin with inelastic turgor
C. apical rate of 110 beats per minute
D. polyuria and excessive thirst - ANSWER A. serum sodium of 185 mEq/L (185mmol/L)
The nurse is obtaining the admission history of a client with suspended peptic ulcer
disease (PUD). which subjective data reported by the client supports this medical
diagnosis.
A. Frequent use of chewable and liquids antacids for indigestion
B. severe abdominal cramps and diarrhea after eating spicy food.
C. upper mid-abdominal pain described as gnawing and burning
D. marked loss of weight and appetite over the last 2 or 4 months - ANSWER c. upper
mid-abdominal pain described as gnawing and burning
the nurse assesses a client who is newly diagnosed with hyperthyroidism and observes
that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye
discomfort. Based on this finding, which action should the nurse include in this client's
plan of care?
A. Assess for signs of increased intracranial pressure
B. Prepare to administer intravenous levothyroxine
C. Review the client's serum electrolyte values
D. Obtain a prescription for artificial tear drops - ANSWER D. Obtain a prescription for
artificial tear drops
To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral
,Sclerosis (ALS), which interventions should the nurse implement? Select all that apply.
A. Perform chest physiotherapy
B. teach the client breathing exercises
C. Initiate passive range of motion excercises
D. Establish a regular bladder routine
E. Encourage use of incentive spirometer - ANSWER A. Perform chest physiotherapy
B. teach the client breathing exercises
E. Encourage use of incentive spirometer
A client is hospitalized with heart failure (HF). which intervention should the nurse
implementation to improve ventilation and reduce venous return
A. Perform passive range of motion exercises
B. Place the client in high Fowler position
C. Administer oxygen per nasal cannula
D. Increase the client's activity level. - ANSWER B. Place the client in high Fowler
position
A client who was involved in a motor vehicle collision is admitted with a fractured left
femur which is immobilized using a fracture traction splint in preparation for an open
reduction internal fixation (ORIF) . The nurse determines that the client distal pulses are
diminished in the left foot. which interventions should the nurse implement? (select all
that apply)
A. verify pedal pulses using a doppler pulse device
B. Evaluate the application of the splint to the left leg
C. Offer ice chips and oral clear liquids
D. Monitor left leg for pain, pallor, paraesthesia, paralysis, pressure
E. Administer oral antispasmodics and narcotic anaglesics. - ANSWER A. verify pedal
pulses using a doppler pulse device
B. Evaluate the application of the splint to the left leg
D. Monitor left leg for pain, pallor, paraesthesia, paralysis, pressure
, A healthcare provider prescribes diagnostic tests for a client whose chest x-ray
indicates pneumonia, which diagnostic test should the nurse review for implementation
in the most therapeutic treatment of the pneumonia?
A. Sputum culture and sensitivity
B. Blood cultures
C. Arterial blood gasses (ABG)
D. computerized tomography (CT) of the chest - ANSWER A. Sputum culture and
sensitivity
A client with a history of asthma and bronchitis arrives at the clinic with shortness of
breath , productive cough with, thickened, tenacious mucous, and the inability to walk
up a flight of stairs without experiencing breathlessness. Which action is most important
for the nurse to instruct the client about self care?
A. Call the clinic if undesirable side effects of medications occur
B. Avoid crowed enclosed areas to reduce pathogen exposure
C. Increase the daily intake of oral fluids to liquefy secretions
D. Teach anxiety reduction methods for feeling of suffocation - ANSWER Increase the
daily intake of oral fluids to liquefy secretions
The home health nurse provides teaching about insulin self injection to a client who was
recently diagnosed with diabetes mellitus. When the client begins to perform a return
demonstration of an insulin injection into the abdomen, as seen in the video, which
instruction should the nurse provide. watch the video
A. Select a different injection site
B. continue with the insulin injection
C. Keep the skin flat rather than bunched
D. lie down flat for better skin exposure - ANSWER B. continue with the insulin injection
The nurse observes an increased number of blood clots in the drainage tubing of a client
with continuous bladder irrigation following a trans-urethral resection of the prostate
(TURP) What is the best initial nursing action
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