Integumentary
Which nursing intervention can help a client maintain healthy skin?
A. Keep the client well hydrated.
The nurse understands that the client with pernicious anemia will have which of the following distinguishing laboratory findings?
B. Intrinsic factor, absent
Which of the following blood tests is most indicative of cardiac damage?
A. Troponin I
A significant cause of venous thrombosis is:
D. All of the above
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?
C. Schedule for A STAT computer tomography (CT) scan of the head.
A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:
A. Turn him frequently.
A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection?
A. Hematocrit
When administered a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of this drug is to:
B. Dissolve clots he may have.
A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for:
B. Smoking history.
What is the expected outcome of thrombolytic drug therapy?
C. Dissolved emboli
A male client visits the physician’s office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to prescribe:
D. A topical agent
A client with anemia may be tired due to a tissue deficiency of which of the following substances?
C. Oxygen
The most important long-term goal for a client with hypertension would be to:
C. Make a commitment to long-term therapy.
Which of the following characteristics is typical of the pain associated with DVT?
C. Sudden onset
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
C. A blood pressure of 220/120 mmHg.
A male client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse’s primary concern should be:
D. Pain management
Which of the following symptoms is expected with hemoglobin of 10 g/dl?
A. None
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to:
A. Check the client status and lead placement.
Cholesterol, frequently discussed in relation to atherosclerosis, is a substance that:
D. Circulates in the blood, the level of which usually decreases when unsaturated fats are substituted for saturated fats.
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?
D. Nail bed pressure
Which of the following clients would least likely be at risk of developing skin breakdown?
C. A client with decreased sensory perception.
The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12?
C. Meats and dairy products
A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted two (2) days ago. The nurse would plan to do which of the following next?
A. Review the intake and output records for the last two (2) days.
Intravenous heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available in the nursing unit?
D. Protamine sulfate
A client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client?
B. Ensuring the return of the gag reflex before offering foods or fluids