A client is admitted with thrombocytopenia. What will the nurse implement to address this
problem? • Bleeding precautions
The nurse would expect to find which symptoms in a client who has hemophilia? • Joint pain &
bleeding
A client is being treated with epoetin alfa ( Epogen). The nurse would explain to the client that the
purpose of the medication is to: • Increase production of red blood cells
The nurse is caring for a client with a hemoglobin level of 8.2 gm/dl. What are important nursing
measures? • Assess for tachycardia; keep warm
A child is recovering from a sickle cell crisis. To promote health in this child after discharge., What is
important for the nurse to discuss with the parents? • Maintain good hydration status
A client has been dx. With pernicious anemia, what will the nurse discuss with the client regarding
the Vit-B12 he will be Rx. When he is discharged? • He will need to have monthly inj. Of Vit-B12
A client begins receiving iron therapy because of an iron-deficiency anemia. The nurse would
encourage The client to take the iron supplement: • Between meals
The nurse is providing dietary teaching for the parent of a child with iron-deficiency anemia. Which
of the following foods would the nurse encourage the parent to include in the child’s diet? • Liver,
dark green, leafy vegetables; and whole grains
A client in sickle cell crisis is admitted to the ER. What are the priorities of nursing care? Hydration,
oxygenation, pain management
A client with congestive heart failure (CHF) has digoxin ordered. In evaluating the therapeutic
effectiveness of the drug, what would the nurse expect to find? Increased cardiac output and
decreased heart rate.
A client is being discharged with sublingual nitroglycerin tablets. What is important to teach him?
Take one nitroglycerin tablet at the onset of chest pain.
Which statement by the client indicates that the client understands how to take sublingual
nitroglycerin? “If I have chest pain, I’ll immediately stop what I am doing, sit down, and the take
the medication.”
The nurse is administering nitroglycerin sublingually to relieve chest pain. What is the therapeutic
action of this medication? Increases the coronary blood supply and increases vasodilation.
An older adult client is taking digoxin (Lanoxin). Prevention of low serum potassium levels for this
client is particularly important. What effect do low potassium levels have on digitalis? Increases the
rate of digitalis toxicity.
Digitalis has been ordered for a client in congestive heart failure. What would the nurse expect to
find when evaluating for the therapeutic effectiveness of the drug? Improved respiratory status
and increased urinary output.
A client with a diagnosis of angina is being discharged. What is important to teach the client
regarding how to take the sublingual nitroglycerin tablets? Take the medication at the first sign of
chest pain.
The nurse is administering nitroglycerin to a client who is complaining of chest pain. What would the
nurse identify as a common side effect of this medication? Client complains of a headache.
What would be important information to obtain in order to evaluate the progress of a client with
congestive heart failure (CHF)? Weight gain or loss
The nurse is assessing a client 2 days after he was diagnosed with a myocardial infarction. What
finding would cause the most immediate concern? Irregular pulse rate of 120 bpm.
The nurse is caring for a client with chronic pulmonary condition who has developed a complication
of right-sided heart failure. Which nursing observation is associated with this complication? Jugular
A cardiac catheterization is scheduled for a client. In considering allergic reactions to the dye used in
the procedure, an allergic reaction to what food would cause the nurse the most concern? Shellfish.
The nurse is preparing a client for a cardiac catheterization. What is important for the nurse to
explain to the client regarding his care after the test? “It will be important for you to lie flat for
several hours vein distention.
After cardiac catheterization, the nurse explains to the client the importance of increasing his fluid
intake. What is the goal of this nursing intervention? Promote excretion of the contrast dye used
during coronary angiography.
A client is admitted for evaluation of his permanent pacemaker. What data would the nurse identify
as a confirming that the pacemaker is not working correctly? Pulse rate of 48 bpm with irregular
beats
The nurse is assessing a client whose condition is being stabilized after a myocardial infarction (MI).
What finding on the nursing assessment would indicate inadequate renal perfusion? Urine output
of less than 30ml/hr.
The nurse is caring for a client with right-sided heart failure (cor pulmonale). What nursing
assessment information correlates with an increase in venous pressure? Jugular vein distention
with client sitting at a 45-degree angle.
The nurse is preparing a client for a cardiac catheterization. What is the best explanation regarding
the purpose of a cardiac catheterization with coronary angiography? Evaluate coronary artery
blood flow.
The nurse is caring for a client with congestive heart failure. How would the nurse accurately
evaluate the fluid balance in this client? Weigh the client daily before breakfast.
An 80 year old man has a long history of congestive heart failure (CHF) and is being admitted to the
hospital. The admitting nurse would assess the client for which of the following symptoms?
Orthopnea, restlessness, and wet breath sounds
A client has just returned from his cardiac catheterization. His right femoral artery was the insertion
site. What is a priority nursing action? Monitor the temperature and pulse of the right lower leg.
A client is scheduled for a 3 pm cardiac catheterization today. What is the most important
assessment for the nurse to make before the client has a cardiac catheterization? Determine the
status of the pulses of the lower extremities.
When should the nurse determine the client’s pulse rate by checking the apical heart rate?
✓ Determining pulse rate before the administration of digitalis.
✓ Determining the heart rate in a client with an irregular pulse.
✓ Determining vital signs on an infant.
A client with PD disease has been experiencing anorexia and vomiting since he began receiving
levedopa. What will be the initial nursing activity?
adult administration medication with food
An older adult client diagnosed with Parkinson’s disease has been prescribed levadopa (l lopa). What
nursing observation would indicate the medication is working?
extremities
decrease in tremors in upper
What nursing activities would assist in the prevention of complications in a client who is recovering
from stroke? encourage mobility and deep breathing
What best nursing measure to prevent constipation client after a stroke or cerebral vascular
accident? encourage mobility and deep breathing
A client is admitted with a seizure activity. The nurse would recognize generalized (tonic-clonic)
seizure activity by: loss of consciousness and sustained intermittent contractions of all large
muscle groups
A client has a diagnosis of chronic renal failure. The laboratory results indicate hypocalcemia.
During the nursing assessment the nurse would alert for which of the following: select all that apply
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Irregular pulse
Abdominal cramping
Trousseau sign
Irritability
A client is beginning long-term medication therapy with methylprdnisolone (soluMedrol)
The medication will decrease the client inflammatory response and ability to fight
infection
A client arrives at the ER complaining that he has had several episodes of epistaxis. The client also
states that he is taking warfin (Coumadin) and his stools test positive for the presence of blood.
What medication would the nurse anticipate administering? Vitamin K
The nurse would question which medication order for a client who is receiving heparin? Asprin
Which instruction should be included in discharge teaching for the client with a new prescription for
simvastatin (zocor)? Liver enzymes levels should be monitored every few months
10.The nurse is caring for a client with Buerger’s disease. What would be the most important
information to discuss with the client regarding this condition? stop smoking
What is included in the nursing management of a client with deep vein thrombosis? Foot of bed
elevated and bed rest
The nurse is told in report that a hypertensive client has been started on medications and has been
experiencing orthostatic hypotension. What considerations will the nurse make in caring for this
client?
assist the client to sitting position and allow him to sit on the side of the bed before
standing.
13.For hours after aortic femoral bypass graft surgery the nurse assess the client and is unable to
palpate pulses in the operative leg. The client complains of pain in the leg. What is the first nursing
action? call the physician immediately.
14.Which statement made by the client to the nurse can best b attributed to her varicose leg veins?
“My legs ache and feel tired after prolonged standing”.
Which modification is most approriate to add to the client’s care plan at this time? Refrain from
massaging the client’s legs.
Which drug should the nurse plan to have available in case it becomes necessary to counteract the
effects of heparin therapy? Protamine sufate.
A client has had her blood pressure evaluated weekly for 1 month. At the end of the month the
nurse averages the weekly. BPs at 150/96 mm Hg. The client is 20 lb overnight, and her cholesterol
is 240 mg/dl. What is important information for the nurse to include in the teaching plan for this
client? Decrease sodium intake and decrease the dietary calories from fat.
Which nursing action would be most effective in preventing venous stasis in the hospitalized client?
Assist the client to walk as soon and as often as possible.
A client’s is immobilized with a pelvic fracture and is at risk for developing deep vein thrombi. What
nursing actions are appropriate to help this complication? Encourage the client to perform active
ROM on all extremities.
A client has been on bed rest for the past 3 days in the morning report the nurse is told the client
has developed thrombophlebitis in the left leg. The nurse would anticipate with finding on
assessment? The left leg is warm with red streaks along the calf.
The nurse is caring for a client with problems of peripheral vascular disease. His history indicates a
problem with intermittent claudication. How would the nurse identify the occurrence of this
problem? Pain is associated with activity.
Which statement offers the best evidence that this client understands the risk for bleeding? “I
must report having tar-colored stools.”
The nurse explains to the client that, because of taking warfin (Coumadin) the client should avoid
eating foods containing large amounts of vitamin K . Which foods should the client limit? Select all
that apply.
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Fresh spinach
Lettuce
turnip greens
Brussels sprouts.
The client asks the nurse if it is safe to resume taking her dietary supplements and herbal
medications after discharge. The nurse responds that much is unknown about dietary supplements.
Considering the client’s condition and medication regimen, which dietary supplements are likely to
alter the client’s international normalized ratio (INR) and prothrombin time (PT) ?Select all that
apply.
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Gingko
St. John’s wort,
Willow bark
Ginger.
Which finding would the nurse expect to document if the client begins developing phlebitis at the
I.V. site? The vein is red and feels warm.
What is the first action the nurse when suspecting phlebitis at an I.V. site? Remove the needle or
catheter from the current site.
Considering the client’s diagnosis, in which part of the body would the nurse expect the client’s
symptoms to be chiefly located? Hands.
27.Which factor is the client most likely to correlate with the onset of the discomfort? Exposure to
cold.
When preparing this client’s teaching plan, the nurse should include information on the importance
of avoiding which activity? Emotional stress.
The nurse would expect the client to report which early symptom of thromboangitis obliterans?
Leg pain accompanying walking or exercise.
30.The nurse observes that the client performs the exercises correctly when the client lies flat with
the legs elevated for several minutes and then performs which action? Sits on the edge of the
bed.
31.When preparing discharge instructions, what activity should the nurse warm the client to avoid?
Tobacco use
A patient is receiving 5 U of U100 regular insulin at 7:30 AM daily. Based on this info, when would be
the most likely time for patient to experience an insulin reaction? Around 11 AM
A patient is placed on insulin sliding scale. The nurse would anticipate which medication being
administered? Regular insulin
A patient in the emergency room is diagnosed with insulin shock. The nurse anticipate which
medication to be ordered? Glucagon
A diabetic patient receives a combination of Regular and NPH insulin at 7am. The nurse would
observe patient S/S of hypoglycemia? 11AM & 5PM
A patient with type 2 diabetes is scheduled with major abdominal surgery. How will the nurse
anticipate controlling blood glucose levels in this patient during the immediate post-op period?
Administer insulin on a sliding scale basis
A patient newly diagnosed with Type 1 DM is learning about diabetic foot care. The nurse would
instruct patient to avoid? Foot soaks
The nurse is caring with patient who has Addison’s disease. How will the nurse evaluate patient with
complications associated with this condition? Evaluate patient with presence of fluctuating b/p
readings
A patient experiences a “thyroid storm”, after removal of his thyroid gland. Nurse understand that
the cause of complication is: Thyroid hormones moving into the bloodstream during thyroid
surgery
A 49 year old client with cancer of the lung just had thoracentesis. The nurse would position the
client: On the unaffected side
Vancomycin 500mg in 250ml of IV solution is to be administered over 90 min. IV Piggyback.
Calculate the rate in drops per minute using a drop factor of 20 gtt/ml. 56 gtt/min.
A 60 year old man is scheduled for suprapubic resection of the prostate in the morning. He discusses
with you that he is worried about his sexual functioning after surgery. Your most appropriate
response would be: “I understand your concern, but most men do not experience a problem after
surgery”
Cardiac tamponade= pericardial tap (pericardocentesis) performed to remove excess fluid and
restore normal heart function.
A 40 year old man has developed stomatitis after chemotherapy treatment. He should be
encouraged to:
Brush his teeth after each meal and at bedtime
Which acid base disturbance would be most characteristic of a narcotic overdose Respiratory
acidosis
A female client is receiving external beam irradiation for squamous cell cancer of the lung. After 2
weeks Of treatment, her skin in the treatment field is red and warm to touch. Your best response
would be to Apply which of the following? Nothing, but notify the doctor
A 50 year old female client is thrombocytopenic (decreased platelets) secondary to chemotherapy.
She complains of nausea and vomiting. All of the following medications are ordered on an as needed
basis. Which medication would be the most appropriate for the client to receive?
Prochlorperazine maleate (Compazine) 10 mg IV push
Your client is receiving continuous enteral nutrition via an NG tube. Which of the following
Interventions is the most important to prevent aspiration?
Keeping the head of the bed elevated
While assisting a client with right-sided hemiparesis to ambulate, the nurse should stand on the Pt.:
Right side and hold one arm around the client’s waist
A 33 year old client has pneumonia. When the nurse assesses this client, the following data will
Receive highest priority: Restlessness, chest wall movement, color of nails
A 46 year old client is on a ventilator and is receiving positive end-expiratory pressure. He starts
Sweating profusely, the pulse increases to 122 bpm, the trachea is deviated to the right, and breath
Sounds on the left are diminished. The nurse would prepare for a possible: Pneumothorax
The nurse is teaching a 56 year old client about hypertension. This nurse recognizes a need for more
Instruction when the client makes the following statement: “I can stop taking my B/P medicine
when I feel all right”
A friend calls and states that he has taken three nitroglycerin tablets for his chest pain, but the pain
is still there. The nurse advises him to : Call 911
A 47 year old client is in acute CHF after an MI. The goal of highest priority for this client at this time
is To: Decrease the workload of the heart
This is the second post-op day for a 54 year old client who had a CABG. At 8 am her B/P is normal;
the Pulse rate is 123 bpm (normally 82 bpm) and weak. The client is cold, clammy and confused.
Her Respiratory rate is 44/min; bowel sounds are absent, and the urinary output is 22 ml/hr. The
nurse Prepares for the treatment of; Shock
The nurse is about to administer a dose of digoxin to a client. The client states that she has not
eaten her Breakfast and complains of being nauseated and having visual changes. After checking her
apical and Radial pulses and the serum digoxin level, the nurse would: Review the latest
electrolyte report
A 33 year old client is admitted to a nursing unit complaining of pain and swelling in her left leg. She
Has a positive Homans’ sign and is diagnosed with DVT. An appropriate nursing intervention would
be: Provide bed rest
A 48 year old client with leukemia is receiving chemotherapy. Depression of bone marrow is a
Possible side effect. The nurse would assess for any signs of infection and/or anemia. The nurse
would also observe for: Bleeding
A client with AIDS indicates that more teaching about the condition is needed when the nurse hears
the Following statement; I’m afraid to touch anyone, I might give them my disease
The nurse recognizes that a client needs more teaching about prevention of peptic ulcer disease
(PUD) After he states; I will miss my morning coffee so much
A 36 year old client recently returned from the operating room after having a partial gast rectomy
for Peptic ulcer disease. He has an NG tube that has been connected to low, intermittent suction for
2 days. A nurse would observe for: Metabolic alkalosis
A 39 year old client has an ileal conduit after recent surgery for cancer of the bladder. The nurse
assesses the amount and characteristics of the drainage, the fluid and electrolyte balance of the
client, and the condition of the stoma and surrounding skin and for: Bowel sounds
A 27 year old client has chest tubes connected to a Pleur-evac after a stab wound to the left chest.
When The client goes to radiology via wheelchair, the nurse would manage the Pleur-evac in the
following way: Attach the Pleur-evac to the side of the wheelchair
A 33 year old client recently had an inguinal hernia repair. The nurse modifies postoperative care
from That given most general surgery clients as follows: Hemorrhage is not as likely in this client
A 16 year old client complains of abd. Pain. The nurse: Checks for rebound tenderness
A client has been given a dx. Of acute pancreatitis. The nurse will assess this client for:
Hyperglycemia
A 33 year old client is undergoing peritoneal dialysis for acute renal failure. To prevent one of the
Most common complications of peritoneal dialysis, the nurse: Uses strict aseptic technique
A 56 year old client just returned from the operating room after having a TURP for cancer. The nurse
Will give highest priority to assessing for: Urinary output
A 62 year old client is receiving radiation treatments for lung cancer. The field for radiation therapy
is clearly outlined with purple ink. The nurse would treat this field as follows: Wipe it with clear
water and pat dry as needed only
A client who has received continuous enteral tube feedings for a week has pulled her NG tube out.
Within an hour, she develops tachycardia, diaphoresis, and tremors of her hands. The nurse
correctly Identifies her symptoms as: Hypoglycemia
A client has been placed on oral anticoagulants after an MI. Which of the following instructions
should The nurse give to the client? The client should carry identification indicating that he or she
is taking an anticoagulant
The nurse is assessing a client who has recently been found to be hyperthyroid. The nurse would
expect To find which of the following symptoms? Has a rapid pulse on rest and exertion
A client is admitted with a dx. Of peptic ulcer disease (PUD). Which of the following symptoms
would Alert the nurse that the ulcer has perforated? Pain is noted in the right shoulder
After a thyroidectomy, a client develops spasms of the hands and feet accompanied by muscle
twitching. The nurse identifies these symptoms as signs of: Hypocalcemia
Which of the following statements made by a client indicates that a complication of peritoneal
dialysis is Occurring? The drainage from my catheter is cloudy and white in color
A 34 year old recently married man is admitted for an ileal conduit urinary diversion. The nurse
should: Explore the clients self-concept and self-esteem before surgery
A client has an intra-aortic balloon pump in the 1:2 mode. He wants to get out of bed to use the
commode. What is the best explanation as to why this is not recommended? The position of the
balloon catheter will be altered in the upright position blocking left subclavian artery Perfusion.
The clients’ heart rate is 60 beats per minute per internal pacemaker, cardiac output is 6 L per
minute,
Pulmonary capillary wedge pressure is 12 mm Hg. And systemic vascular resistance is 900 dynes. If
the Cardiologist increases the intrinsic rate of the pacemaker to 75 beats per minute, which of the
following is The nurse likely to see in the clients’ homodynamic monitoring:
Cardiac output will
increase
A 26 year old male presents to the ER with exercise induced asthma. Assessment findings that
confirm His dx. Are: ( select all that apply)
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Wheezing
Chest tightness
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Cough
Silent chest
Diminished breath sounds
The client had a craniotomy for removal of a glioma 48 hrs. ago. Identify all priority nursing
Assessments:
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Level of consciousness
Pupil response
Vital signs
Condition of the surgical dressing
Turning and positioning
Encouraging adequate nutrition
Assessing pain
A 49 year old client with cancer of the lung just had a thoracentesis. The nurse would position the
client: On the unaffected side
Nurse’s highest priority for client with bilateral adrenalectomy in the immediate postoperative
period: Monitor fluid and electrolyte balance sign of hypoglycemia and hypotension