Alteration in Oxygenation
A nurse is assessing a client suspected of having influenza. Which of the following symptoms would differentiate influenza from the common cold?
a) Sneezing and nasal congestion
b) Gradual onset of symptoms
c) Fever, muscle aches, and chills
d) Mild cough with clear sputum
Answer: c) Fever, muscle aches, and chills
A nurse is teaching a client about preventing postural hypotension. Which of the following should be included in the teaching?
a) "Change positions slowly from lying to sitting to standing."
b) "Drink less water to prevent fluid retention."
c) "Increase caffeine intake to raise blood pressure."
d) "Avoid compression stockings to allow for proper circulation."
Answer: a) "Change positions slowly from lying to sitting to standing."
A nurse is assessing a client with suspected deep vein thrombosis (DVT). Which of the following findings is expected?
a) Bilateral lower extremity swelling
b) Warmth and redness over the affected area
c) Generalized pallor and bradycardia
d) Cool skin temperature in the affected limb
Answer:
b) Warmth and redness over the affected area
A client with asthma is having an acute exacerbation. Which of the following findings is most concerning to the nurse?
a) PaO₂ 80 mm Hg and PaCO₂ 50 mm Hg
b) Presence of inspiratory and expiratory wheezing
c) Inability to speak and profuse sweating
d) Peak expiratory flow rate at 60% of personal best
Answer: c) Inability to speak and profuse sweating
A nurse is caring for a client experiencing angina. Which finding is most concerning and requires immediate intervention?
a) Chest pain that occurs with exertion and is relieved with rest
b) Chest pain that radiates to the jaw and persists despite rest
c) A blood pressure reading of 140/90 mm Hg
d) A complaint of fatigue after climbing stairs
Answer: b) Chest pain that radiates to the jaw and persists despite rest
A client with acute myeloid leukemia (AML) is experiencing fever and chills. What is the priority nursing action?
a) Administer acetaminophen as prescribed.
b) Encourage oral fluid intake.
c) Initiate neutropenic precautions and notify the healthcare provider.
d) Obtain a sputum culture
Answer:
c) Initiate neutropenic precautions and notify the healthcare provider.
A nurse is teaching a client about allergic rhinitis management. Which statement by the client indicates a correct understanding?
a) "I will use my nasal steroid spray only when I have symptoms."
b) "I will avoid exposure to allergens when possible."
c) "Allergic rhinitis is caused by bacterial infections, so antibiotics are needed."
d) "I should rinse my sinuses with tap water to clear allergens."
b) "I will avoid exposure to allergens when possible."
Answer: b) "I can stop taking my medication once my blood pressure is normal."
A nurse is caring for a client in a sickle cell crisis. Which nursing intervention is the highest priority?
a) Encourage ambulation to prevent deep vein thrombosis.
b) Apply cold compresses to painful joints.
c) Administer IV fluids and oxygen as prescribed.
d) Restrict fluid intake to prevent overload.
Answer:
c) Administer IV fluids and oxygen as prescribed.
The nurse is preparing a client diagnosed with small-cell lung carcinoma (SCLC) for discharge. What is the most important point to include in discharge teaching?
a) "Your cancer has a slow progression, so symptoms may develop over years."
b) "Your cancer is highly responsive to chemotherapy, but frequent follow-ups are required."
c) "SCLC is usually caught early, so prognosis is generally good."
d) "Surgery is the first-line treatment for SCLC."
Answer: b) "Your cancer is highly responsive to chemotherapy, but frequent follow-ups are required."
A client with left-sided heart failure is experiencing pulmonary edema. Which of the following interventions should the nurse perform first?
a) Administer prescribed diuretics
b) Place the client in a high-Fowler’s position
c) Monitor daily weights
d) Encourage fluid intake
Answer: b) Place the client in a high-Fowler’s position
A client with immune thrombocytopenic purpura (ITP) who is a Jehovah’s Witness refuses a blood transfusion. What is the best nursing action?
a) Educate the client on the importance of receiving blood products.
b) Administer corticosteroids and thrombopoietin receptor agonists as prescribed.
c) Contact the hospital’s legal team for a court order.
d) Prepare the client for an emergency blood transfusion.
Answer:
b) Administer corticosteroids and thrombopoietin receptor agonists as prescribed.
The nurse is reviewing the ABG results of a client with late-stage COPD. Which of the following findings is expected?
a) pH 7.52, PaCO₂ 30 mm Hg, HCO₃⁻ 35 mEq/L
b) pH 7.40, PaCO₂ 40 mm Hg, HCO₃⁻ 25 mEq/L
c) pH 7.32, PaCO₂ 58 mm Hg, HCO₃⁻ 30 mEq/L
d) pH 7.30, PaCO₂ 45 mm Hg, HCO₃⁻ 18 mEq/L
c) pH 7.32, PaCO₂ 58 mm Hg, HCO₃⁻ 30 mEq/L
A nurse is caring for a client in hypertensive crisis. Which of the following interventions should the nurse prioritize?
a) Encourage the client to drink more fluids
b) Administer antihypertensive medication as prescribed
c) Ambulate the client immediately to reduce blood pressure
d) Provide the client with high-sodium foods to stabilize blood pressure
Answer: b) Administer antihypertensive medication as prescribed
A nurse is reviewing the laboratory findings of a client with disseminated intravascular coagulation (DIC). Which of the following results should the nurse expect?
a) Increased platelet count
b) Decreased D-dimer level
c) Increased prothrombin time (PT) and activated partial thromboplastin time (aPTT)
d) Elevated hemoglobin and hematocrit levels
Answer:
c) Increased prothrombin time (PT) and activated partial thromboplastin time (aPTT)