which client has the highest risk for developing skin cancer?

a 65 year old fair-skinned client who is a construction worker

The nurse is caring for a client in the post anesthesia care unit who
underwent a thoracotomy two hours ago. The nurse observes the following
vital signs: HR 140 bpm, RR 26 bpm, and BP 140/90 mmHg. Which
intervention is most important for the nurse to implement?

encourage the client to splint the incision with a pillow to cough and deep
breathe

An older client with long term type 2 DM is seen in the clinic for a routine
health assessment. Which assessments would the nurse complete to
determine if a patient with type 2 DM is experiencing long term
complications? SATA

sensation in feet and legs, skin condition of lower extremities, visual acuity

A client with Cushing's syndrome is recovering from an elective laparoscopic

procedure. Which assessment finding warrants immediate intervention by
the nurse?

irregular apical pulse

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the
feet and legs, and massive ascites. Which mechanism contributes to edema
and ascites in clients with cirrhosis?

Hypoalbuminemia that results in a decreased colloidal oncotic pressure

While caring for a client with full thickness burn covering 40% of the body,
the nurse observes purulent drainage at the wound. Before reporting this to
the healthcare provider, the nurse should review which of the following of the
client's lab values?

WBC

A nurse is caring for a client with diabetes insipidus. Which data warrants the
most immediate intervention by the nurse?

serum sodium of 185

We have an expert-written solution to this problem!

The nurse is obtaining the admission history for a client with suspected
peptic ulcer disease, which subjective data reported by the client supports
this medical diagnosis?

upper mid abdominal pain described as gnawing and burning

The nurse assesses a client who is newly diagnosed with hyperthyroidism

and observes that the client's eyeballs are protuberant, causing a wide-eyed
appearance and eye discomfort. Based on this finding, which action should
the nurse include in this client's plan of care?

obtain a prescription for artificial tear drops

To reduce the risk of pulmonary complication for a client with amyotrophic

lateral sclerosis, which interventions should the nurse implement? SATA

perform chest physiotherapy, teach the client breathing exercises,

encourage use of incentive spirometer

A client is hospitalized with heart failure. which intervention should the nurse
implement to improve ventilation and reduce venous return?

place the client in high fowler

A client who was involved in a motor vehicle collision is admitted with a

fractured left femur which is immobilized using a fracture traction splint in
preparation for an ORIF. The nurse determines that the client's distal pulses
are diminished in the left foots. Which intervention should the nurse
implement?SATA

verify pedal pulses with doppler, evaluate application of the splint to left leg,
monitor for pain, pallor, paresthesia, paralysis, and pressure

The healthcare provider prescribes diagnostic tests for a client whose chest
xray indicates pneumonia. which diagnostic test should the nurse review for
implementation in the most therapeutic management of pneumonia?

sputum culture with sensitivity

A client with a history of asthma and bronchitis arrives at the clinic with
shortness of breath, productive cough with thickened, tenacious mucous, and
the inability to walk up a flight of stairs without experiencing breathlessness.
Which action is most important for the nurse to instruct the client about self-
care?

increase the daily intake of oral fluids to liquify secretions

We have an expert-written solution to this problem!

The nurse is planning care for an older adult client who experienced a
cerebrovascular accident several weeks ago. The client has expressive
aphasia and often become frustrated with the nurse staff. Which intervention
should the nurse implement?

encourage use of picture charts

A client with gouty arthritis report tenderness and swelling of the right ankle
and great toe. The nurse observes the area of inflammation extends above
the ankle area. The client receives prescriptions for colchicine and
indomethacin. Which instruction should the nurse include in the discharge
teaching?

drink at least 8, 8 ounces of water per day

The home health nurse provides teaching about insulin self injection to a
client who was recently diagnosed with DM. When the client begins to
perform a return demonstration of an insulin injection into the abdomen as
seen in the video, which instruction should the nurse provide?

Continue with the insulin injection

The nurse observes an increased number of blood clots into the drainage
tubing of a client with continuous bladder irrigation following a trans-urethral
resection of the prostate (TURP). Which is the best initial nursing action?

increase the flow of irrigation

We have an expert-written solution to this problem!

Four days following an abdominal aortic aneurysm repair, the client is

exhibiting edema of both extremities, and the pedal pulses are not palpable.
Which action is first?

assess pulses with a vascular doppler

A client arrives to the unit 4 hours after a TURP. A triple -lumen catheter for
continuous bladder irrigation with normal saline water is infusing and the
nurse observes dark, pink tinged outflow with blood clots in the tubing and
collection bag. Which action should the nurse take?

monitoring catheter drainage

When conducting discharge teaching for a client diagnosed with

diverticulosis, which diet instruction should the nurse include?

eat a high fiber and increase fluids

After three days of persistent epigastric pain, a female client presents to the
clinic. she has been taking oral antacid without relief. her vital signs are HR
122, RR 16, O2 96%, BP 116/72. The nurse obtains a 12 lead ECG. Which
assessment finding is most critical?

ST elevation in three leads

A client with acute renal injury weighs 50kg and has potassium levels of 6.7
is admitted ot the hospital. which prescribed medication should the nurse
administer first?

sodium polystyrene sulfonate 15 grams by mouth

A client receives a prescription for 1 L of lactated ringers IV to be infused

over 6 hours. How many ML/Hr should the nurse infuse the pump. to deliver?

167

a client with a history of PUD is admitted after vomiting bright red blood
several times over the course of 2 hours. In reviewing the lab results, the
nurse finds the client's Hg is 12, Hct is 35. Which action should the nurse
prepare to take?

give 1000 NS

an obese client with emphysema who smokes at least a pack of cigarettes

daily is admitted after experiencing a sudden increase in dyspnea and
activity intolerance. Oxygen therapy is initiated, and it is determined that the
client will be discharged with oxygen. Which information is most important
for the nurse to emphasize in the discharge teaching plan?

guidelines for oxygen use

which food is most important for the nurse to encourage a client with
osteocalcin to include in daily diet?

fortified milk and cereals

A client with Herpes Zoster (shingles) on the thorax tells the nurse of having
difficulty sleeping. Which is the probable etiology of this problem?
a. frequent cough
b. pain
c. nocturia
d. dyspnea

pain

The nurse is caring for a client who is postoperative for a femoral fracture
repair. which interventions should the nurse plan to administer for DVT
prophylaxis?

compression devices, calf pump exercises, anticoagulant therapy

a client with lung cancer who wears a sub Q morphine sulfate patch for pain
is short of breath and is difficult to arouse. When performing a head to toe
assessment, the nurse discovers 4 analgesic patches on the client's body?

administer a narcotic antagonist

a client with cholelithiasis is admitted with jaundice due to obstruction of the

common bile duct. Which finding is most important for the nurse to report to
the healthcare provider?

distended, hard, rigid, abdomen

The nurse is collecting information from a client with a chronic pancreatitis

who reports persistent gnawing abdominal pain. to help the client manage
the pain, which assessment data is most important for the nurse to obtain?

eating patterns and dietary intake

A client who had a C-5Spinal cord injury 2 years ago is admitted with the
diagnosis of automatic dysreflexia secondary to a full bladder. Which
assessment finding should the nurse expect for the client to exhibit>

pain and burning sensation upon urination and hematuria

During spring break, a young adult presents at the urgent care clinic and
reports a stiff neck, fever for the past 6 hours, and a headache. Which
intervention is most important for the nurse to implement?
a. initiate isolation precautions
b. prepare for a lumbar puncture
c. admin an antipyretic
d. draw blood cultures
initiate isolation precautions

The nurse assesses a client with petechiae and ecchymosis scattered across
the arms and legs. Which lab results should be reviewed

platelet count

An older adult client with a long history of COPD is admitted with progressive
SOB and a persistent cough. The client is anxious and is complaining of a dry
mouth. Which intervention should the nurse implement?

assist client to upright position

The nurse is providing discharge instructions to a client who is receiving

prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which
symptom should the nurse tell the client to report to the healthcare
provider ?

rapid weight loss

While completing a health assessment for a client with migraine headaches,

the nurse assesses bilateral weakness in the client's hand grips. the client
reports joint pain and trouble twisting a door knob due to weakness. Which
action should the nurse take?

consult with OT for a functional assessment

An adult who was recently diagnosed with glaucoma tells the nurse "it feels
like I am going through a tunnel". The client expresses great concern about
going blind. Which instruction is most important for the nurse to provide this
client?

maintain prescribed eye drop regimen

A client with a history of T1DM and asthma is readmitted to the unit for the
third time in 2 months with a current BS of 325. The client describes to the
nurse of not understanding why the BS level continues to be out of control.
Which interventions should the nurse implement?

have client describe a typical day at work, home and socially; have the client
demonstrate how they monitor BS levels

The nurse is caring for a client who is receiving teletherapy radiation for a
malignant tumor. Which instructions regarding skin care of the portal site
should the nurse provide?

protect the skin of the radiation portal site from sunlight exposure
The health care provider prescribes penicillin 200,000 units IM for a client
with pneumonia. The available vial is labeled penicillin 500k units/ML. How
many ML shoudl the nurse administer to this client

0.4

An adult client is diagnosed with restless leg syndrome and is referred to the
sleep clinic. The HP prescribes ferrous sulfate 325 MG PO daily. Which lab
values should the nurse monitor?

serum iron and ferritin

The nurse is developing a plan of care for a client who reports blurred vision
and who is newly diagnosed with cardiovascular disease. Which outcome
should the nurse include in the plan of care for this client?

daily BP less than 140/80 this month

A hospitalized client with PAD is instructed regarding leg and foot care. which
statement by the client indicates to the nurse that learning has occured?

i can use a mirror to check to bottoms of my feet and for breakdown

The nurse is preparing a client for surgery who was admitted to the ER
following a motor vehicle collision. the client has an open fracture of the
femur and is bleeding during the pre-op assessment. The nurse determines
that the client currently receives Hep sodium 5000 mL daily. What is the
priority action?

notify PCHP of medication history

A client with orthopnea expresses concern about the ability to "get enough
air" during a scheduled thoracentesis. On which information should the
nurse's response be based on?

the procedure is performed with the client in an upright position

The nurse is providing teaching to a client with T2DM and peripheral

neuropathy. Which information should the nurse provide?

family members can help with foot exams

A client in the operation room received succinycholine. the client is

experiencing muscle rigidity and has an extremely high temperature. which
action should the nurse implement first

prepare ice packs for placement in the client's axillary area

A client receives prescriptions for a multidrug regimen for the treatment of
tuberculosis. Which info should the nurse prioritize?

adherence to the regimen is imperative

The nurse is obtaining a health history from a new client who has a history of
kidney stones. which statement by the client indicates an increased risk for
renali calculi?

eats a vegetarian diet with cheese 2-3 times daily

a client tells the nurse about experiencing burning on urination, and

assessment reveals that the client had sexual intercourse four days ago with
a person who was casually met. Which action should the nurse implement?

obtain a specimen of urethral drainage for culture

An adult is admitted with flank pain and is diagnosed with acute

pyelonephritis. What is the priority nursing action?

administer IV antibiotics as prescribed

The family suspects that AIDS dementia is occurring in their son who is HIV
positive. Which symptom confirms their suspicions?

a change has recently occurred in his handwriting