1. A client has had heart failure. Which intervention is most important for the
nurse to
implement prior to the initial administration of Digoxin to this client?
A) Assess the apical pulse, counting for a full 60 seconds
B) Take a radial pulse, counting for a full 60 seconds
C) Use the pulse reading from the electronic blood pressure device
D) Check for a pulse deficit
The correct answer is A: Assess the apical pulse, counting for a full 60 seconds
2. A client is admitted with a tentative diagnosis of congestive heart failure.
Which of
the following assessments would the nurse expect to be consistent with this
problem?
A) Chest pain
B) Pallor
C) Inspiratory crackles
D) Heart murmur
The correct answer is C: Inspiratory crackles
3. A nurse is providing care to a 17 year-old client in the post-operative care unit
(PACU) after an emergency appendectomy. Which finding is an early indication that
D) Pulse oximeter reading of 92%
The correct answer is C: Increasing pulse rate
4. Which order can be associated with the prevention of atelectasis and pneumonia
in a
client with amyotrophic lateral sclerosis?
A) Active and passive range of motion exercises twice a day
B) Every 4 hours incentive spirometer
C) Chest physiotherapy twice a day
D) Repositioning every 2 hours around the clock
The correct answer is C: Chest physiotherapy twice a day
5. A client who was medicated with meperidine hydrochloride
(Demerol) 100 mg and
hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a
fractured lower right leg 1 hour ago reports that the pain is getting worse.
The nurse
should recognize that the client may be developing which complication?
A) Acute compartment syndrome
B) Thromboemolitic complications
C) Fatty embolism
D) Osteomyelitis
The correct answer is A: Acute compartment syndrome
6. The nurse is assessing an 8 month-old child with atonic cerebral palsy.
Which
statement from the mother supports the presence of this problem?
A) When I put my finger in the left hand the baby doesn’t respond with a grasp.
B) My baby doesn’t seem to follow when I shake toys in front of the face.
C) When it thundered loudly last night the baby didn’t even jump.
D) When I put the baby in a back lying position that’s how I find the baby. The correct
answer is D: Unable to roll from
7. Which statements by the client would indicate to the nurse an
understanding of the
issues with end stage renal disease?
A) I have to go at intervals for epoetin (Procrit) injections at the health department.
B) I know I have a high risk of clot formation since my blood is thick from too many
red
cells.
C) I expect to have periods of little water with voiding and then
sometimes to have a lot
of water.
D) My bones will be stronger with this disease since I will have higher
calcium than
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