Exam 1: Changes in Health

A client diagnosed with severe anemia is receiving packed red blood cells. Around fifteenminutes after the infusion is started, the client complains of itching, lower back pain, shortness of breath, and development of hives on the chest area. The client has chills and fever. Which of the following should the nurse do first?

A nurse auscultates the heart of Anne, a 21-year-old female. Anne seeks a consultation for dizziness and easy fatigability. During assessment, the nurse identifies a mid-to-late systolic click followed with mid-to-late systolic murmur at the cardiac apex. The murmur gets louder when Anne stands up. Based on these findings, Anne is most likely considered for which of the following cardiac problems?

A nurse is assigned to care for a client who was recently admitted due to dyspnea. The chart notes that the client has an endotracheal tube in place. Suctioning is ordered every four hours. The nurse keeps in mind that prior to suctioning, which of the following is performed first?

Adams, a 63-year-old retired bookkeeper, comes to the emergency unit with complaints of nausea and vomiting, muscle weakness, and fatigue. Nursing assessment includes a blood pressure of 180/100 mmHg and a slow irregular pulse rate. ECG results show shortened QT intervals. Which of the following electrolytes is most likely elevated?

A nurse is closely monitoring a female client who is admitted due for depression. The nurse determines which behavior as an indicator that the client is suicidal?

Marc, a 30-year-old client, is rushed to the emergency department due to mental status changes. Physical examination reveals dilated pupils, tachycardia, and hypertension. The nurse prepares to administer which of the following medications to the client?

The fifteen-year-old daughter of a client diagnosed with schizophrenia asks the nurse about her chances of having the same disorder. Which of the following statements, if made by the client, would be an indication that the girl should be evaluated further?

Michelle is a 37-year-old female experiencing severe diarrhea that contains blood and mucus. The client is admitted to the facility for treatment. After a series of tests, the client is diagnosed with ulcerative colitis. The nurse caring for the client implements which of the following as the priority intervention during the acute phase of ulcerative colitis?

A nurse is receiving a ten-year-old child from the post-anesthesia care unit who has just undergone a tonsillectomy. The nurse ensures the child's safety by placing the child in which of the following positions?

A female client can take some oral nutrition, but her food intake is not enough to meet the needs of her body. A total parenteral nutrition is ordered for a week. Only small amounts of carbohydrates, fats, and proteins are required. The nurse expects the physician to deliver the nutrients in which of the following veins?

A nurse arrives at an emergency scene. The nurse determines that which of the following clients is least in need of an emergency assessment?

Briana, a newlyhired nurse, is tasked with caring for female client who has an endotracheal tube in place. Suctioning is ordered, when needed. The nurse manager should intervene when Briana performs which of the following actions during suctioning?

Which of the following infants should the nurse see first?

Janna, a 52-year-old female, had a surgical procedure with permanent ileostomy. A nurse gives an enema through the stoma to stimulate emptying. Which of the following actions by the nurse demonstrates proper technique of irrigating the colostomy?

Wanda comes to the emergency department complaining of substernal chest pain that radiates to the neck and left arm. A 12-lead electrocardiogram is attached to Wanda to evaluate the function of the heart. A nurse examines the tracing, which suggests myocardial ischemia. Which of the following electrocardiogram changes is most likely noted by the nurse?

A physician orders corticosteroid therapy to a female client with Addison's disease. The nurse informs the client that steroid administration can lead to a number of side effects. The nurse lists all of the following as common side effects of corticosteroids EXCEPT:

A female teenaged client comes to the emergency room following an assault. The client is extremely anxious and is hyperventilating. Which of the following interventions is the most appropriate nursing action?

A nurse is teaching a client who has just been prescribed aluminum hydroxide. The nurse would instruct the client to do which of the following?

A nurse is assigned to care for Amanda, a 39-year-old lawyer who was recently diagnosed with generalized anxiety disorder. Which of the following statements from Amanda would lead the nurse to suspect that Amanda's anxiety has been a long-standing problem?

A client in her third trimester is admitted due to painless, bright red vaginal bleeding. The vital signs were obtained and the external monitor has been applied. What is the next action of the nurse?