Mobility
A 72-year-old man is recovering from a left total hip replacement. The unlicensed assistive personal reports that the patient keeps trying to cross his legs at the knee while sitting in a chair. Which instruction should the nurse give the UAP to help prevent complications?
A. "Allow him to cross his legs if it reduces his pain"
B. "Place a firm pillow between his knees and remind him not to cross his legs"
C. "Have him sit in a low chair so he is more comfortable"
D." Encourage him to bend forward at the waist to reach his feet and relieve pressure"
B. "Place a firm pillow between his knees and remind him not to cross his legs"
A nurse notes a client’s Glasgow Coma Scale score decreased from 14 to 10 over 2 hours. What is the priority nursing action?
Correct Answer: 2
Rationale:
A drop in GCS indicates worsening neurological function. Priority is immediate ABC assessment due to risk of respiratory compromise.
A 72 year old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause?
A. A diagnosis of diabetes treated with insulin and diet
B. An exercise regimen of jogging 3 miles four times a week
C. A history of cardiac disease
D. Advancing age
D. Advancing age
Advancing age is a significant risk factor for the development of cancer, including lung cancer. As individuals age, cellular damage accumulates over time, increasing the likelihood of abnormal cell growth and mutations that can lead to cancer. Although smoking is the leading risk factor for lung cancer, nonsmokers can still develop the disease due to factors such as age, environmental exposures, genetics, and prior lung disease.
Option A is incorrect because diabetes is not a primary risk factor for lung cancer. Option B is incorrect because regular exercise generally helps reduce cancer risk. Option C is incorrect because cardiac disease is not directly associated with the development of lung cancer.
A nurse is caring for a client who is 6 hours postoperative from a transurethral resection of the prostate (Transurethral Resection of the Prostate). Which finding requires the nurse’s immediate intervention?
Correct Answer: 3
Rationale:
After TURP, continuous bladder irrigation is used to prevent clot formation and maintain catheter patency. A sudden absence of urine output suggests possible catheter obstruction from clots, which can lead to bladder distention, increased bleeding, and possible rupture. This is an emergency and requires immediate intervention. Light pink urine and mild bladder spasms are expected findings in the early postoperative period, and adequate urine output is reassuring.
A client diagnosed with Addison's disease has a care plan emphasizing increased dietary sodium intake to prevent complications of adrenal insufficiency. During meal planning, the nurse reviews available food choices. Which option should the nurse recommend to best support this client's treatment goals?
A. Graham crackers
B.Cheddar cheese
C. Raw carrots
D. Canned fruit
B. Cheddar cheese
A client is admitted following a motor vehicle collision and sustained a long bone fracture. During assessment, the nurse notes dark tea-colored urine. Laboratory results reveal elevated creatine phosphokinase (CPK) and myoglobin levels. The client also reports flank pain. Which intervention is the nurse’s priority?
A. Administer prescribed opioid analgesics for flank pain
B. Initiate IV fluid therapy and closely monitor urine output
C. Apply cold compresses to the fractured extremity
D. Place the client on strict bed rest to prevent further injury
Correct answer: B
The client is demonstrating manifestations of rhabdomyolysis, a complication of severe muscle trauma that can lead to acute kidney injury. Dark tea-colored urine, elevated CPK, and myoglobin levels indicate muscle breakdown and myoglobin release. The priority intervention is aggressive IV hydration to flush myoglobin through the kidneys and prevent renal failure.
A nurse is caring for a client immediately after surgical removal of a cataract via Cataract surgery. Which action is the priority in the immediate postoperative period?
Correct Answer: 3
Rationale:
After cataract surgery, the priority is to reduce intraocular pressure and prevent disruption of the surgical site. The client should be positioned supine with the head of bed elevated to promote drainage and reduce pressure in the eye. Ambulation and bending at the waist should be avoided in the immediate postoperative period, and positioning on the operative side is not recommended due to pressure on the affected eye.
A female client with cancer is scheduled to undergo radiation therapy. The nurse understands that radiation can cause certain adverse effects regardless of the treatment site. Which common side effect should the nurse prepare the client to expect?
A. Hair loss
B. Stomatitis
C. Fatigue
D. Vomiting
C. fatigue
A nurse is caring for a client diagnosed with a small bowel obstruction. The client reports abdominal pain, nausea, and vomiting, and the abdomen is distended. Which action is the nurse’s initial priority?
2. Prepare the client for insertion of a nasogastric (NG) tube for decompression
In a small bowel obstruction, the priority is to relieve pressure and prevent further complications such as perforation and worsening distention. Insertion of a nasogastric (NG) tube for decompression helps remove accumulated gastric contents and gas, reducing pressure within the bowel. Pain control, ambulation, and fluid management are important but are not the immediate priority before decompression.
A client with diabetes insipidus is admitted to the emergency department with severe dehydration. The nurse notes excessive dilute urine output, dry mucous membranes, tachycardia, and hypotension. Which intervention should the nurse anticipate as the priority treatment?
A. 0.45% normal saline
B. 3% hypertonic saline
C. D5W with potassium restriction
D. Lactated Ringer’
A. 0.45% normal saline
The nurse receives a report on the 6-month-old child with a congenital abnormality of the hip who is in Bryant traction. Which observation upon entering the patient's room indicates the patient is positioned appropriately?
A. The knee and hip are maintained at 90-degree angles
B. The head of the bed is in high fowlers position
C. The buttocks is suspended just above the bed
D. The knees are level with the mattress
C. The buttocks is suspended just above the bed
Bryant's traction is used for young children with a femur fracture and certain congenital abnormalities of the hip. A key part of the traction is that the buttocks are held up off the mattress, usually with the legs straight. The legs and torso form nearly a 90-degree angle. Bryant's traction is generally used for children under 2 years and weighing less than 30 pounds.
A nurse is caring for a client diagnosed with Meniere's disease who report sudden onset of severe vertigo, tinnitus, and a sensation of the room "spinning". The client is visibly anxious and unsteady while standing.
Which nursing intervention is the priority?
A. Encourage the client to ambulate
B. Administer prescribed Meclizine
C. Provide a high- sodium snack to stabilize inner ear fluid balance
D. Turn off all lights and place the client in a supine position with head elevated
B. Administer prescribed Meclizine
The nurse is teaching a 47-year-old woman about recommended screening practices for breast cancer. Which statement by the client indicates understanding of the nurse's instruction?
A. My mother and grandmother had breast cancer, so I am at risk
B. I get a mammogram every 2 years since I turned 30
C. A clinical breast examination is performed every month since I turned 40
D. A CT scan will be done every year after I turn 50
A. My mother and grandmother had breast cancer, so I am at risk
A family history of breast cancer, especially in first-degree relatives such as a mother, increases a woman’s risk for developing breast cancer. This statement demonstrates correct understanding of breast cancer risk factors. Option B is incorrect because routine mammograms are not typically recommended every 2 years beginning at age 30 for average-risk women. Option C is incorrect because clinical breast examinations are performed by a healthcare provider during routine visits, not every month by the client. Option D is incorrect because CT scans are not recommended as routine annual screening for breast cancer; mammography is the standard screening tool.
A nurse is assessing a client suspected of having Ulcerative Colitis. Which assessment finding is most indicative of this condition?
Correct Answer: 2
Rationale:
Ulcerative colitis is characterized by inflammation of the colon that typically presents with frequent episodes of watery diarrhea containing blood and mucus, along with urgency and abdominal cramping. Fistulas are more commonly associated with Crohn’s disease, while semi-formed stool or alternating constipation is not as characteristic of an active ulcerative colitis flare.
A nurse is caring for a client following a total thyroidectomy. Which postoperative findings should the nurse recognize as potential complications of the procedure? (Select all that apply.)
A. Laryngeal nerve damage
B. Hemorrhage
C. Hyperglycemia
D. Airway edema and swelling
E. Wound dehiscence
F. Hypocalcemia
G. Deep vein thrombosis
A, B, D, E,F
The nurse is observing a staff member caring for a client who has compartment syndrome. Which of the following action by the staff member would require the nurse to intervene?
A. elevating the affected extremity above the level of the heart
B. assessing for a distal pulse in the affected extremity
C. preparing supplies for a fasciotomy of the affected extremity
D. placing a cold compress bandage to the affected extremity
E. applying a compression bandage to the affected extremity
A, D, E
Compartment syndrome occurs when pressure builds up within a closed muscle compartment, causing decreased blood flow and tissue ischemia. The priority is to maintain adequate perfusion to the affected extremity and prevent further increases in pressure.
A nurse notes that a client has difficulty swallowing and a weak gag reflex. Which cranial nerve is most likely impaired?
1. Vagus nerve assessment
*300 POINT QUESTION*
A 39-year-old client visits the gynecologist for an examination. After the assessment, the physician suspects cervical cancer. The nurse reviews the client's history to identify potential risk factors for this disease. Which of the following findings in the client's history is a known risk factor for cervical cancer?
Onset of sporadic sexual activity at age 17
Spontaneous abortion at age 20
Pregnancy complicated by eclampsia at age 25
Human papillomavirus (HPV) infection at age 30
Human papillomavirus (HPV) infection at age 30
A nurse is providing discharge teaching to a client with a newly created Ostomy appliance system. Which supplies should the nurse instruct the client to use during routine ostomy care?
Select all that apply.
A. Adhesive wafer barrier
B. Drainable pouch
C. Urinary catheter kit
D. Skin protective barrier wipes
E. Stoma paste or sealant
F. Sterile saline irrigation set
G. Clip or closure device
H. Central line dressing kit
A. Adhesive wafer barrier
B. Drainable pouch
D. Skin protective barrier wipes
E. Stoma paste or sealant
G. Clip or closure device
The nurse is caring for a client diagnosed with pheochromocytoma. Which findings would the nurse expect?
Select all that apply.
A. Severe hypertension
B. Bradycardia
C. Tachycardia
D. Headache
E. Hypoglycemia
F. Excessive diaphoresis
A, C, D, F
A patient with a newly applied plaster cast for a fractured tibia is receiving instructions from the nurse. Which of the following statements require further teaching? (Select 4-6 choices)
A. I should keep my cast dry at all times
B. I can scratch under the cast with a long safe object if it itches
C. I should elevate my leg to reduce swelling
D. it is normal to experience pain and numbness
E. I should apply ice over the cast to reduce swelling
F. I can bear weight on my leg as soon as the cast is applied
G. I will call the doctor if i notice any foul odor coming from the cast
H. I should refrain from wiggling my toes until the cast is removed
I. I should use the hair dryer on cool to dry the cast if it gets wet
B, D, F, H
A nurse is caring for a client experiencing a generalized tonic-clonic seizure related to Epilepsy. Which actions should the nurse take during the seizure?
Select all that apply.
1. Turn the client onto their side
2. Insert an oral airway
3. Loosen restrictive clothing around the neck
4. Time the duration of the seizure
5. Restrain the client’s arms and legs to prevent injury
6. Place padding under the client’s head
7. Administer oral fluids to prevent dehydration
1, 3, 4,6
*400 POINT QUESTION*
A male client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
Stand as far away from the implant as possible and call for help.
Pick up the implant with long-handled forceps and place it in a lead-lined container.
Leave the room and notify the radiation therapy department immediately.
Put the implant back in place using forceps and a shield for self-protection, and call for help.
Pick up the implant with long-handled forceps and place it in a lead-lined container.
A nurse is caring for a client diagnosed with Glomerulonephritis. Which findings would the nurse expect?
Select all that apply. (4-6)
A. Cola-colored
B. Periorbital and facial edema
C. Proteinuria
D. Hypertension
E. Low urine specific gravity (1.001)
F. Oliguria
G. Clear yellow urine with high output
H. Hypotension
I. Hypovolemia
A. Cola-colored
B. Periorbital and facial edema
C. Proteinuria
D. Hypertension
F. Oliguria
A nurse is reviewing laboratory findings for a client suspected of having Syndrome of Inappropriate Antidiuretic Hormone Secretion. Which findings would the nurse expect?
Select all that apply. (2-4 choices)
A. Serum sodium 128 mEq/L
B. Serum osmolality 260 mOsm/kg
C. Urine specific gravity 1.035
D. Serum sodium 150 mEq/L
E. Urine specific gravity 1.002
F. Serum osmolality 310 mOsm/kg
A, B, C