1. The home health nurse is performing a home safety assessment for an older adult client with a hearing impairment who uses a cane.
Which of the following client statements requires follow-up? Select all that apply.
A. “l enjoy taking baths for stress relief..
B. “l have a raised toilet seat in my bathroom.”
C. “My friend bought a beautiful new rug for my hallway.”
D. “l use a space heater for extra warmth on cold nights.”
E. “My daughter comes by once a week to fill my medication organizer.”
2. The emergency department charge nurse must transfer a client from the emergency department to the telemetry unit to make a bed available in the emergency department.
It would be most appropriate for the nurse to transfer out the client with
A. sepsis who has a blood pressure of 88/52
B. atrial fibrillation who has lV diltiazem ordered
C. ulcerative colitis who has a fever and diarrhea
D. chronic bronchitis who requires oxygen via nasal cannula
3. The nurse has been made aware of the following client situations.
The nurse should first assess the client with
A. influenza reporting headache and malaise
B. sickle cell disease reporting itching and leg pain
C. pyelonephritis with persistent fever of 100.7 F(38.4 C)
D. congestive heart failure experiencing dyspnea on exertion
4. The nurse is notified of the following client situations.
It would be a priority for the nurse to follow up with the
A. 72-year-old male with pneumonia who is coughing up blood-tinged sputum
B. 36-year-old female with pancreatitis who has a temperature of 99.8 F (37.6 C)
C. 56-year-old female with a history of diabetes who reports indigestion and left shoulder pain
D. 36-year-old male with a history of Crohn disease with a new colostomy who reports skin irritation at the site
5. The nurse is teaching a pregnant client about her new diagnosis of preeclampsia.
Which of the following information should the nurse include?
A. “lf you experience continuous heartburn, call the office for evaluation.”
B. “You will be on complete bed rest with bathroom privileges until after delivery.”
C. “Take your blood pressure once a week and report increased readings to your health care provider.”
D. “Don’t be alarmed if you experience blurred vision and headaches since it is expected with preeclampsia.”
6. The nurse in the inpatient psychiatric unit is leading a support group for clients.
It would be a priority for the nurse to intervene if the client with
A. schizophrenia has not spoken and is staring intently at the corner of the room
B. major depressive disorder is expressing feelings of isolation and loneliness with the group
C. generalized anxiety disorder has moved to the back of the room and is engaging in deep breathing exercises
D. histrionic personality disorder is saying that another group member’s symptoms are not severe enough to beattending the session
7. The nurse is preparing to administer digoxin to a client with heart failure.
Which of the following laboratory test results would the nurse review before administering the medication?
A. Sodium level
B. Platelet count
C. Potassium level
D. B-type natriuretic peptide
8. The nurse has taught a client who is newly prescribed pyridostigmine for myasthenia gravis (MG).
Which of the following statements by the client would indicate a correct understanding of the teaching?
A. “| will wait to take this medication until 1 hour after l eat a meal.”
B. “I can stop taking this medication if it makes me feel sick to my stomach.”
C. “Taking this medication as prescribed can reverse my myasthenia gravis.”
D. “I should notify my primary health care provider if l experience excess sweating.”
9. The nurse is talking with a client who is being discharged from the hospital after coronary angiography for a myocardial infarction.
Which of the following statements by the client would require follow-up?
A. “l will gradually build up my activity to 150 minutes of brisk walking weekly.”
B. “| will set an alarm to take clopidogrel and aspirin at the same time every day.”
C. “I can resume sexual activity once l am able to comfortably climb 2 flights of stairs.”
D. “I can take naproxen to help with any aches and pains from my new exercise routine.”
10. The nurse is caring for a client who has a crush injury to the left lower leg.
It would be a priority for the nurse to monitor the client’s
A. pain level
B. urinary output
C. oral temperature
D. pedal pulse strength