Physiological Adaptation 2

A nurse discusses the potential side effects of radiation with a client preparing for radiation therapy for breast cancer. Which of the following statements should the nurse include in the teaching?

A nurse assesses a woman in an obstetric clinic that is 35 weeks pregnant. Which of the following symptoms described by the client requires further investigation?

A nurse is assessing a client on 2L O2 via a nasal cannula with a chest tube for management of a pneumothorax. Which of the following findings is expected of the chest tube drainage system?

A nurse is repositioning a client with a hemothorax following thoracic trauma. The client has bilateral chest tubes placed. As the nurse repositions the client, the nurse realizes that one of the chest tubes has dislodged. Which action should the nurse take next?

The nurse is caring for a client on a ventilator for pneumonia secondary to influenza. Which of the following nursing diagnoses is least appropriate for the client?

The graduate nurse is preparing to suction a client with a tracheostomy. Which action by the graduate nurse requires additional intervention?

A nurse is changing a sterile dressing on a subclavian central line. Place the following steps of the dressing change in the appropriate order.

A. Apply non-sterile gloves.
B. Prepare sterile field and central line dressing kit.
C. Cleanse the insertion site with an antiseptic swab.
D. Apply sterile gloves.
E. Apply new dressing.
F. Remove old dressing.

A nurse is caring for a client with epilepsy and the presence of tonic-clonic seizures. The client’s caregiver calls out to the nurse that the client has started convulsing. Which of the following is the priority nursing action?

The nurse is caring for a client in the intensive care unit on a ventilator for acute respiratory failure. Which of the following nursing interventions would be inappropriate for the client?

The nurse is caring for a newborn male requiring a bili light for neonatal jaundice. Which of the following nursing actions should the nurse take while caring for the infant?

The nurse is changing a dressing on an open sacral wound on an immobile client. Which of the following assessment findings requires further investigation?

A 72-year-old client post-op abdominal laparoscopy asks the nurse how to use an incentive spirometer. Which of the following statements by the nurse is most appropriate?

A 79-year-old client comes to the hospital with concerns about tuberculosis. The charge nurse on the shift understands that the client should be assigned to which of the following rooms?

A nurse is caring for a 17-year-old client post-op open pyeloplasty. Which statement by the client indicates a need for further coping support?

Which of the following clients is at the highest risk for dehydration?

A 68-year-old client presents to the emergency department following a crush injury to the leg. The client has required 1 unit of packed red blood cells and 1 L of isotonic fluid. The client develops crackles and dyspnea. The nurse anticipates that these symptoms are a result of which of the following?

A client in the intensive care unit no longer requires continuous blood pressure monitoring via an arterial line. Which of the following actions should the nurse take when removing the arterial line?

A client presents to a clinic with presumed cholecystitis. Which of the following assessment findings does the nurse anticipate?

A post-op client’s caregiver calls out urgently to the nurse that there is something coming out of the client’s abdominal incision. The nurse assesses the patient and realizes that the client’s intestine is protruding out of the surgical incision. Which of the following is the priority nursing action?

A 73-year-old client requires a Foley catheter for accurate intake and output measurements. Which of the following nursing diagnoses is most appropriate for the client?