Question: A nurse caring for a client who is vomiting should identify the risk for which acid-base imbalance?
Answer Choices:
Metabolic alkalosis
Metabolic acidosis
Respiratory acidosis
Respiratory alkalosis
Answer: Metabolic alkalosis
Question: A suicidal client declines a safety contract. What is the priority nursing action?
Answer Choices:
Provide plastic utensils
Lock doors and windows
Remove self-harm objects
Assign staff to stay with client at all times
Answer: Assign a staff member to stay with the client at all times
Question: A nurse notes a systolic click during auscultation. Which condition is indicated?
Answer Choices:
Aortic regurgitation
Aortic stenosis
Mitral stenosis
Mitral valve prolapse
Answer: Mitral valve prolapse
Question: The nurse is caring for older adults. Which risk factors increase their risk for shock? (Select all that apply.)
Answer Choices:
Overhydration
Decreased thirst response
Diminished immune response
Malnutrition
Altered mobility/immobility
Answer: Decreased thirst response, Diminished immune response, Malnutrition, Altered mobility/immobility
Question: A patient arrives to the ED with a burn injury following a house fire. Which of the following manifestations would best alert the nurse of an inhalation injury? (Select all that apply.)
Answer Choices:
Soot in sputum
Singed nasal hairs
Decreased respiratory rate
Facial burns
Hoarseness
Answer: Soot in sputum, Singed nasal hairs, Facial burns, Hoarseness
Question: A nurse caring for a client with acute respiratory failure should monitor for which manifestations? (Select all that apply.)
Answer Choices:
Hypotension
Nausea
Decreased LOC
Severe dyspnea
Headache
Answer: Decreased level of consciousness, Severe dyspnea
Question: After a left antecubital cardiac catheterization, which pulse should the nurse palpate?
Answer Choices:
Radial pulse in left arm
Brachial pulse in left arm
Radial pulse in right arm
Brachial pulse in right arm
Answer: Brachial pulse in the left arm
Question: A nurse is caring for a client at risk for shock. What is the earliest indicator?
Answer Choices:
Increased respiratory rate
Decreased LOC
Hypotension
Anuria
Answer: Increased respiratory rate
Question: A nurse cares for a client with cardiogenic pulmonary edema. What is the nurse’s priority?
Answer Choices:
Place in high-Fowler’s with legs dependent
Provide oxygen 5 L/min
Administer morphine sulfate IV
Give sublingual nitroglycerin
Answer: Place the client in high-Fowler’s position with their legs in a dependent position
Question: Which congenital heart defect is associated with a “boot-shaped” heart?
Answer Choices:
Patent ductus arteriosus
Tetralogy of Fallot
Coarctation of the aorta
Hypoplastic left heart syndrome
Answer: Tetralogy of Fallot
Question: A nurse caring for a client with hypertension prescribed propranolol should identify which contraindication?
Answer Choices:
Glaucoma
Depression
Asthma
Migraines
Answer: Asthma
Question: A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). Which finding should the nurse expect when auscultating the client’s apical pulse?
Answer Choices:
Irregular pulsations
Bounding pulsations
Bradycardia
Tachycardia
Answer: Irregular pulsations