Exam 1: Changes in Health

A 23-year-old female at 35 weeks' gestation comes to the emergency department complaining of severe abdominal pain. Moderate dark vaginal bleeding is noted. Physical assessment findings include increased uterine tone with orthostatic changes in the blood pressure. External fetal monitor reveals fetal distress. Based on these initial findings, the client is most likely diagnosed with which of the following conditions?

A client at 32 weeks gestation chokes on her food and becomes unconscious. The nurse's immediate action is to:

Enid is a 25-year-old female client who comes to the emergency department due to tachycardia and palpitations. The client is excessively sweating and is demonstrating signs of weakness. The client informs the nurse that the symptoms started 1 ½ hours after administering her daily insulin. Which of the following is the most appropriate intervention for the client?

A male client with alcohol dependence will be placed on disulfiram therapy. Before the start of the therapy, the nurse reminds the client that disulfiram is an alcohol deterrent, which will sensitize the client to alcohol. The nurse instructs the client to abstain from alcohol for at least:

At 9:00 a.m. a nurse finds a client, being infused with 5% dextrose in 0.9% sodium chloride, is having difficulty breathing. On assessment, the nurse notes increased blood pressure, distended jugular veins, and crackles on auscultation. A 1,000-ml infusion bag of solution was hung at 8:00 a.m. The remaining solution is measured at 600 ml. The nurse's most immediate action is to:

The nurse receives the client assignment for the day. After making her rounds, which of the following clients would be nurse's first priority?

A client with pregnancy-induced hypertension is given magnesium sulfate. Which finding, during assessment, should alert the nurse?

A physician orders regular insulin at 10 units per hour to be administered by IV infusion pump. An IV infusion bag is labeled 100 units of regular insulin in 500 ml of 5% dextrose in water. The nurse prepares to set the infusion pump at how many millimeters per hour?

A client who had open heart surgery 24 hours ago has had a urine output of about 20 ml/hr for the past 12 hours. The laboratory findings reveal a BUN level of 38 mg/dl and a serum creatinine level of 2.0 mg/dl. A nurse reviewing these results determines that the client is at risk for which of the following?

Jane is a 54-year-old female who was recently diagnosed with pulmonary edema. Furosemide, given through intravenous route, is ordered to the client. The nurse caring for the client reviews Jane's chart and finds out that she is also ordered to take digoxin. Which of the following is the priority action of the nurse?

A nurse in the emergency room is caring for an eighteen-year-old girl who is a victim of sexual assault. The client is withdrawn and at times, becomes physically immobile. The nurse determines that:

A nurse is giving discharge instructions to a client with myasthenia gravis about reducing the risk for aspiration when eating. Which of the following is not included in the teachings?

Campbell, a 25-year-old construction worker, is admitted to a burn unit after a fire in a construction site. Initial assessment reveals burn injuries involving the anterior and posterior aspects of the upper extremities. The injured surfaces are black in color and dry in texture. Tissue with fat exposure and edema are noted. Mr. Campbell reports minimal pain. The nurse assessing Mr. Campbell classifies these integumentary injuries as:

A client with persistent cough is complaining of severe pain when coughing. The nurse would instruct the client to do which of the following comfort measures?

A client is admitted to the facility due to right-sided heart failure. The nurse notes that the client demonstrates distention of the jugular vein. The nurse places the head of the bed in which of the following positions to obtain the most accurate jugular venous pressure reading?

Benny, a male client who has been on steroid therapy, has been recently diagnosed with a duodenal ulcer. Which of the following assessment findings is most likely noted in the client's chart?

A client who was admitted to the neurology unit has injuries above T6. A urinary catheter is in place. After the morning care, the client begins to complain of severe headache. Physical examination reveals flushing of face and neck, bradycardia, hypertension, dilated pupils, and piloerection. Which of the following is an appropriate intervention for the client?

An emergency nurse is admitting a 32-year-old female office clerk who was rushed to the emergency department for abdominal pain. Client history reveals occasional episodes of mild abdominal pain that occur especially after eating fatty foods. A significant nursing assessment that indicates inflammation and infection of the gall bladder is:

An eighty-year-old male client diagnosed with benign prostatic hypertrophy complains of pain as the nurse inflates the balloon of the indwelling urethral catheter that has been inserted. What is the best action of the nurse?

LaShonda, a 29-year-old female, is admitted to the unit due to a possible case of hypothyroidism. The client's history and physical assessment findings are indicative of hyposecretion of the thyroid hormones. The nurse expects to note which of the following findings in the client's chart?