RAY A. GAPUZ REVIEW SYSTEM
1. A client is refusing to make medications. The first priority for the nurse is to
Select one:
1. Call the provider to report the non-compliance
2. Demand that the client take the medications
3. Assess the situation by talking to the client
4. Set a mutual goal with the client
2. A home health nurse has been assigned to visit four clients. Based on the information provided, which
client would have the highest priority when detecting on the schedule of visits?
Select one:
1. A colon cancer client with a sigmoid colostomy of 2 months
2. A hypertensive client who has been complaining of an occipital headache for the past 2 days
3. A 3rd day postoperative mastectomy client with a Jackson-Pratt drain
4. A client with emphysema on low-flow oxygen who is complaining of fatigue
3. Following shift report, the nurse would first assess the high-rish antepartal patient who is
Select one:
1. 34-weeks gestation, placenta previa with first episode of mild bleeding
2. 32-weeks gestation, pregnancy-induced hypertension with epigastric pain
3. 24-weeks gestation, hyperemesis with a potassium level of 3.6 mEq/L
4. 16-weeks gestation, gestational diabetic with a fasting blood sugar of 60 mg/dl
4. The nurse has just received change of shift report on the following clients on the labor, delivery,
recovery, and postpartum (LDRP) unit. Which of these clients would the nurse assess first?
Select one:
1. An 18-year-old single primigravida client, in labor for 9 hours, with cervical dilation at 6 cm, 0 station,
contractions occurring every 5 minutes, and receiving epidural anesthesia
2. A 24-year-old primiparous client who delivered a 7 lbs 3 ounce boy vaginally 1 hour ago, as a firm
fundus and scant lochia rubra, and is attempting to breast-feed
3. A 26-year-old mutigravida client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station,
contractions every 3 to 5 minutes, and receiving no anesthesia.
4. A 30-year-old multipara who delivered a 6 pound 5 ounce girl by cesarean section owing to fetal
distress 3 hours ago, has a firm fundus and scant lochia rubra, and is receiving patient controlled
morphine analgesia
5. The nurse is assigned to the following four clients. Which client should the nurse assess first?
Select one:
1. A 50-year-old receiving chemotherapy with a temperature of 101° F
2. A 46-year-old 2 days postoperative an open cholecystectomy
3. A 52-year-old diagnosed diabetic complaining of blurred vision
4. A 40-year-old ready for discharge to a rehabilitation center
6. A patient who has a history of bulimia is brought to the emergency department with a blood pressure
of 76/50 mm Hg. a heart rate of 48/min, lethargy and poor skin turgor. The priority nursing diagnosis for
this client is
Select One:
1. Fluid volume deficit related to laxative abuse
2. Self-esteem disturbance related to distorted body image
3. Alteration in nutrition: less than body requirements, related to binging and purging
4. Knowledge deficit related to maladaptive coping skills
7. To which of the following nursing diagnosis would a nurse give priority when caring for a client in the
postoperative period following an ileostomy?
Select one:
1. Fluid volume deficit
2. Body image disturbance
3. Pain
4. Diarrhea
8. To which of the following nursing diagnoses would a nurse give priority to the care of a patient having
a spinal cord injury at C4.
Select one:
1. Altered health maintenance
2. Impaired skin integrity
3. Altered sensory perception: tactile
4. Ineffective breathing pattern
9. To which of the following nursing diagnoses would a nurse give priority in caring for patient who has
myasthenia gravis?
Select one:
1. Ineffective individual coping
2. Situational low self-esteem
3. Ineffective thermoregulation
4. Risk for aspiration
10. When a patient who has diabetes mellitus experiences peripheral neuropathy, the priority nursing
diagnosis should be:
Select one:
1. Altered health maintenance
2. Altered urinary elimination
3. Risk for impaired skin integrity
4. Noncompliance