Reference no: EM133849725

Question

1. An older client who lives alone in a two-story home is admitted after falling while shopping. X-rays reveal a fractured left hip. With no immediate family in the area, the client is concerned about pets at home. Which interventions should the nurse implement? SATA

a. Palpate and mark pedal pulses

b. Evaluate pain using a standard pain scale

c. Support left leg with two pillows

d. Assess ability to bear weight when standing

e. Alert social worker of client concerns

2. After diagnosis and initial treatment of a 3 year old child with cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child mother indicates that she understands home care treatment to promote pulmonary function?

a. Chest physiotherapy should be performed twice a day before a meal

b. Administer a cough suppressant every 8 hours

c. Energy should be conserved by scheduling minimally strenuous activities

d. Maintain supplemental oxygen at 4 to 6 L/minute

3. A client with deep vein thrombosis (DVT) is receiving continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? SATA

a. Auscultate bowel sounds in all quadrants

b. Review last partial thromboplastin time results

c. Assess characteristics of pain

d. Prepare to administer warfarin

e. Monitor stools presence of blood

4. Which client requires careful nursing assessment for signs and symptoms of hypermagnesemia?

a. A client who developed hyperparathyroidism in late adolescence

b. A female client who is overzealous with her intake of simple carbohydrates

c. A middle aged male client in renal failure following an unsuccessful kidney transplant

d. A young adult client with intractable vomiting from food poisoning

5. The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss. The client daughter who lives close to her father tells the nurse that she will stop daily to check on her father. Which interventions should the nurse implement? SATA

a. Include the family in the discharge teaching

b. Face client when speaking

c. Encourage the client to attend reading classes

d. Speak loudly when teaching

e. Provide the daughter with written instructions

6. The charge nurse is planning for the shift and has a registered nurse and a practical nurse on the team. Which client should the charge nurse assign to the RN?

a. A 75 year old client with renal calculi who requires straining

b. A 64 year old client who had a total hip replacement the previous day

c. An adolescence with multiple contusions due to a fall that occurred 2 days ago

d. A 30 year old depressed client who admits to suicide ideation

7. A client with advanced cirrhosis is being treated for hepatic encephalopathy. In reviewing the client serum laboratory results, which finding requires the most immediate intervention by the nurse?

a. Lowered total protein and albumin

b. Elevated direct bilirubin

c. Decreased ammonia

d. Prolonged prothrombin time (PT)

8. A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continuous positive airway pressure (CPAP). His vital signs are: temperature 98.8 F, heart rate 118 beats/minute, respirations 46 breaths/ minute, blood pressure 176/92 mmHg. While completing the pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurse implement?

a. Administer PRN nebulizer treatment

b. Prepare for rapid sequence intubation

c. Increase the oxygen delivery by 10%

d. Complete neurological assessment