Cardiac
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.
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 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
Glycosylated hemoglobin (HbA1C) test measures the average blood glucose control of an individual over the previous three months. Which of the following values is considered a diagnosis of pre-diabetes?
B. 5.7-6.4%
Which of the following symptoms do you expect to see in a patient diagnosed with acute pyelonephritis?
B. Costovertebral angle tenderness and chills
A murmur is heard at the second left intercostal space along the left sternal border. Which valve is this?
C. Pulmonic
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
B. Pupil size and pupillary response
Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will:
D. Experience less nasal obstruction and discharge.
A client with DM demonstrates acute anxiety when first admitted for the treatment of hyperglycemia. The most appropriate intervention to decrease the client’s anxiety would be to:
D. Convey empathy, trust, and respect toward the client
A 30 y.o. female patient is undergoing hemodialysis with an internal arteriovenous fistula in place. What do you do to prevent complications associated with this device?
B. Avoid taking blood pressures in the arm with the fistula.
A significant cause of venous thrombosis is:
D. All of the above
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
D. An oral anticoagulant medication
The nurse teaches a client with COPD to assess for s/s of right-sided heart failure. Which of the following s/s would be included in the teaching plan?
C. Peripheral edema
A client with type 1 diabetes mellitus has a fingerstick glucose level of 258mg/dl at bedtime. An order for sliding scale insulin exists. The nurse should:
C. Administer the insulin as ordered
The most common early sign of kidney disease is:
B. Elevated BUN level
The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
D. Pulmonary circulation
Which client would the nurse identify as being most at risk for experiencing a CVA?
D. A 55-year-old African American male.
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of COPD secondary to an upper respiratory tract infection. Which of the following findings would be expected?
D. Coarse crackles and rhonchi
The nurse is teaching a client regarding the administration of insulin as part of the discharge plan. Which of the following insulin has the most rapid onset of action?
B. lispro (Admelog)
Which cause of hypertension is the most common in acute renal failure?
B. Hypervolemia
Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation?
A. Exertional dyspnea
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 physical assessment findings would the nurse expect to find in a client with advanced COPD?
A. Increased anteroposterior chest diameter.
A clinical instructor teaches a class for the public about diabetes mellitus. Which individual does the nurse assess as being at the highest risk for developing diabetes?
C. The 42-year-old client who is 50 pounds overweight
What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease?
B. Fluid volume excess