Question 1

A client is rushed to the emergency department after demonstrating signs of acute myocardial infarction. History reveals that the chest pain has not been resolved by sublingual nitroglycerin. The client is started on tissue plasminogen activator by infusion. The nurse caring for the client frequently assesses which of the following parameters?

Accepted Answer

A) Serum potassium levels 
B) Oxygen saturation 
C) Pulse rate 
D) Visual acuity

Question 2

A nurse is giving medication instructions to a client who has been prescribed phenytoin. Which of the following statements, if made by the client, indicates a need for further teaching about taking phenytoin?

Accepted Answer

A) "I need to avoid alcohol while on this medication." 
B) "I need to call my physician if my gums bleed." 
C) "Pink to red urine is harmless." 
D) "I should take my medication with milk."

Question 3

A client comes to the emergency department complaining of dyspnea and has a respiratory rate of 30 breaths per minute. The client receives a diagnosis of pneumonia. Which of the following is the initial action of the nurse?

Accepted Answer

A) Initiate antibiotics, as ordered 
B) Instruct bed rest with bathroom privileges 
C) Administration of oxygen 
D) Encourage consumption of foods high in calories

Question 4

A nurse would see which of the following clients first?

Accepted Answer

A) A client scheduled for thoracentesis in an hour 
B) A client in sickle crisis with an infiltrated IV 
C) A client with a leg cast who is ready for discharge 
D) A client with diabetes who requires a dressing change for a stasis ulcer

Question 5

A female client was admitted to the gastrointestinal unit two days ago. The client has been demonstrating signs of decline in gastrointestinal function for the past day and is now ordered to be transferred to the intensive care unit. Before the transfer, which of the following should the nurse do first?

Accepted Answer

A) Inform the nurse supervisor about the transfer. 
B) Obtain a signed consent. 
C) Search for an accepting physician. 
D) Call the admitting nurse in the ICU.

Question 6

A newlyadmitted male client in an acute manic state kisses a female nurse and asks her to go on a dinner date with him. The nurse's best response is to:

Accepted Answer

A) Ignore the client. 
B) Directly tell the client that his behavior is not acceptable. 
C) Ask the client to help clean the dayroom. 
D) Isolate or seclude the client.

Question 7

Bandes is a 34 year-old sales agent who has chronic low back pain. He has been taking ibuprofen intermittently for the past two years. Two days ago he experienced shooting pain from the lower back and into the buttocks and left leg. He was admitted to the facility for medical management. During the afternoon shift, he complains of mild but persistent headache. The client appears to be irritable. To ease Mr. Bandes's headache and discomfort, nursing care should include:

Accepted Answer

A) Relaying the client's complaints to his attending physician. 
B) Administering the next dose of pain medication. 
C) Decreasing sensory stimulation. 
D) Teaching the client non-pharmacological management of pain.

Question 8

Kelly, a nullipara at 34 weeks' gestation, comes to the emergency department saying, "I think I'm about to go into labor." After assessing the client, the nurse alerts the physician for a possible case of pre-term labor. The nurse then initiates nursing interventions that aim to manage pre-term labor. Which of the following findings would be most likely to lead the nurse to suspect pre-term labor?

Accepted Answer

A) Irregular uterine contractions; cervical dilatation is absent. 
B) Painful uterine contractions occurring every 10 minutes with cervical dilatation. 
C) Painful uterine contractions occurring every 10 minutes without cervical dilatation. 
D) Irregular contractions every 10 minutes with cervical dilation; effacement has not started.

Question 9

Simon, a client with a history of congestive heart failure, complains of shortness of breath. He cannot tolerate lying flat on the bed. Physical examination reveals accumulation of fluid in the left lung. Thoracentesis is ordered. The client must be placed in which of the following positions during the procedure?

Accepted Answer

A) Semi-Fowler's position. 
B) Position of comfort. 
C) Lying on the unaffected side; head of bed elevated to 45-degrees. 
D) Supine, with the right side of the upper abdomen exposed.

Question 10

A physician orders the removal of the client's nasogastric tube. The nurse would instruct the client to do which of the following during tube removal?

Accepted Answer

A) Ask the client to take a deep breath and exhale through pursed lips. 
B) Instruct the client to bear down. 
C) Instruct the client to take and hold a deep breath. 
D) Ask the client to relax and take normal breaths.

Question 11

An 18-year-old male was admitted to the unit after sustaining a head trauma during a football game. The nurse caring for the client recognizes the client's greater risk for increased intracranial pressure. Which of the following findings should alert the nurse as it is the earliest indication of increasing intracranial pressure?

Accepted Answer

A) Bradycardia 
B) Widened pulse pressure 
C) Declining level of consciousness 
D) Elevated temperature

Question 12

Andrea, a 23-year-old female, comes to the clinic for her second pre-natal examination. On physical assessment, bluish discoloration of the mucus membranes of the cervix, vagina, and vulva is noted. This probable sign of pregnancy is called:

Accepted Answer

A) Goodell's sign 
B) Hegar's sign 
C) Chadwick's sign 
D) Ballotement

Question 13

The physician orders the attachment of a client's nasogastric tube to intermittent suction. The nurse attaches the suction, keeping in mind that the pressure should not exceed:

Accepted Answer

A) 25 mm Hg 
B) 20 mm Hg 
C) 15 mm Hg 
D) 10 mm Hg

Exam 1: Changes in Health