Mid Term Questions
The nurse is writing a care plan for an 85-year-old client who has community-acquired pneumonia. The nurse assesses decreased breath sounds to bilateral lung bases on auscultation. What is the most appropriate nursing diagnosis for this client?
Ineffective airway clearance related to tracheobronchial secretions
A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action?
Instill the medication in the conjunctival sac
A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius?
Risk for Infection
Radiographs of a boy's upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture?
What is a greenstick fracture?
A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care?
Surgical intervention
The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the client's health?
Fluid volume status
The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client?
Maintain head of bed (HOB) elevated at 30 to 45 degrees
The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She states that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect?
Hypocalcemia
An adult client has requested a “do not resuscitate” (DNR) order in light of his recent diagnosis with late-stage pancreatic cancer. The client's son and daughter-in-law are strongly opposed to the client's request. What is the primary responsibility of the nurse in this situation?
Honor the request of the client
A nurse is providing a class on osteoporosis at the local seniors' center. Which of the following statements related to osteoporosis is most accurate?
Slow discontinuation of corticosteroid therapy can halt the progression of the osteoporosis.
An older adult client has symptoms of osteoporosis and is being assessed during her annual physical examination. The assessment shows that the client will require further testing related to a possible exacerbation of her osteoporosis. The nurse should anticipate what diagnostic test?
Bone densitometry
During a comprehensive health assessment, which of the following structures can the nurse best assess by palpation?
Thyroid gland
The admissions department at a local hospital is registering a male older adult for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this client?
Advance directives are limited only to health care instructions and directiv
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid–base imbalance?
Respiratory alkalosis
A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus
Cardiac and respiratory status
A client is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the client, the nurse instructs the client to immediately call the office if the client experiences what?
A new floater in vision
A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood?
The client is likely experiencing a delayed onset of respiratory complications
Assessment of a client's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
What is an ulcer?
An infectious outbreak of unknown origin has occurred in a long-term care facility. The nurse who oversees care at the facility should report the outbreak to what organization?
Centers for Disease Control and Prevention (CDC)
A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharg
Client is able to perform transfers safel
The nurse is performing a health assessment of an adult male client. The man states, “The doctor has already asked me all these questions. Why are you asking them all over again?” What is the nurse's best response?
This history helps us determine what your needs may be for nursing care.”
A client has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action?
Contact the primary provider immediately
The nurse on the medical–surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications?
Cholinergics
A nurse is caring for a client who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention?
Intermittent application of heat to the client's back
A nurse is caring for a client who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the client faces a high risk of what infectious complication?
Osteomyelitis