A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to: A. Call the physician B. Place a saline-soaked sterile dressing on the wound C. Take blood pressure and pulse D. Pull the dehiscence closed Correct Answer: B.… Read More »
Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation should the nurse report to the physician immediately? A. Pitting edema of the legs B. An irregular apical pulse C. Dry mucous membranes D. Frequent urination Correct Answer: B. An irregular apical pulse Because Cushing’s syndrome causes… Read More »
A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be: A. Flank pain radiating in the groin B. Distention of the lower abdomen C. Perineal edema D. Urethral discharge Correct Answer: B. Distention of the lower abdomen This indicates that the… Read More »
With which of the following disorders is jugular vein distention most prominent? A. Abdominal aortic aneurysm B. Heart failure C. Myocardial infarction D. Pneumothorax Correct Answer: B. Heart failure Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump. Option A: Jugular vein distention… Read More »
Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Stokes respirations. Cheyne-stokes respirations are: A. Progressively deeper breath followed by shallower breaths with apneic periods. B. Rapid, deep breathing with abrupt pauses between each breath. C. Rapid, deep breathing and… Read More »
Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus? A. Above-normal urine and serum osmolality levels. … Read More »
A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child’s symptoms? A. Possible fracture of the tibia. B. Bruising of the gastrocnemius… Read More »
What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention? A. High-Fowler’s B. Raised 10 degrees C. Raised 30 degrees D. Supine position Correct Answer: C. Raised 30 degrees Jugular venous pressure is measured with a centimeter… Read More »
Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: A. Tracheal B. Fine crackles C. Coarse crackles D. Friction rubs Correct Answer: B. Fine crackles Fine crackles are caused by fluid in the alveoli and… Read More »
Tissue plasminogen activator (t-PA) is considered for the treatment of a patient who arrives in the emergency department following the onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA? A. Worsening chest pain that began earlier in the evening B. History of cerebral hemorrhage … Read More »