The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis? A. Alteration in cerebral tissue perfusion B. Fluid volume deficit C. Ineffective airway clearance D. Alteration in sensory perception … Read More »
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment? A. Determine the level at which the patient has intact sensation. B. Assess the level at which the patient has retained mobility. C. Check blood pressure and pulse for signs… Read More »
Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis? A. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t. B. Osteoarthritis is a localized disease rheumatoid arthritis is systemic. C. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized. D. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t. … Read More »
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time? Altered tissue perfusion Risk for fluid volume deficit High risk for hemorrhage Risk for infection … Read More »
Stimulation of the sympathetic nervous system produces which of the following responses? A. Bradycardia B. Tachycardia C. Hypotension D. Decreased myocardial contractility Correct Answer: B. Tachycardia Stimulation of the sympathetic nervous system causes tachycardia and increased contractility. Norepinephrine released from neurons via the right stellate ganglion increases… Read More »
A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with I.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which… Read More »
Terence suffered from burn injury. Using the rule of nines, which has the largest percent of burns? A. Face and neck B. Right upper arm and penis C. Right thigh and penis D. Upper trunk Correct Answer: D. Upper trunk The percentage designated for each burned part… Read More »
A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement? A. Transfusion reaction is most likely immediately after the infusion is completed. B. PRBCs are best infused slowly through a 20g. IV catheter. C. PRBCs should be flushed with a… Read More »
A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms? A. Myocardial infarction due to a history of atherosclerosis. B. Pulmonary embolism due… Read More »
Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output? A. Angina pectoris B. Cardiomyopathy C. Left-sided heart failure D. Right-sided heart failure Correct Answer: D. Right-sided heart failure Weight gain, nausea, and a decrease in urine output are secondary… Read More »