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The nurse has just administered a purified protein derivative (PPD) tuberculin skin test (Mantoux test) to a client who is at low risk for developing tuberculosis. The nurse determines that the test is positive if which occurs?
The nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. Which finding would the nurse expect to note if this disorder was present?
The nurse is reviewing the record of a client with a disorder involving the inner ear. Which finding would the nurse most likely note as an assessment finding in this client?
What would the nurse consider when determining whether a client diagnosed with chronic obstructive pulmonary disease (COPD) could tolerate and benefit from active progressive relaxation? Select all that apply.
The nurse reviews the results of a blood chemistry profile for a client who is experiencing late-stage salicylate poisoning and metabolic acidosis. Which serum study would the nurse review for data about the client’s acid-base balance?
A client with a diagnosis of diabetes mellitus has a blood glucose level of 644 mg/dL (35.8 mmol/L). The nurse interprets that this client is at risk of developing which type of acid-base imbalance?
The nurse has a prescription to administer hydroxyzine in conjunction with an opioid analgesic for severe pain to a client by the intramuscular route. Before administering the medication, what information would the nurse share with the client?
An adult client suspected of having developed encephalitis has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. After reviewing the results of the analysis, the nurse recognizes that the CSF is suggestive of the infection when which element is noted?
A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing?
The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which interventions would be helpful for this type of incontinence? Select all that apply.
The nurse caring for a client diagnosed with a stroke is planning care to maintain nutritional status. The nurse is concerned about the client’s swallowing ability. Which food item would the nurse eliminate from this client’s diet?
A client is resuming a diet after a Billroth II procedure performed because of gastric carcinoma tumor. To minimize complications associated with eating, which actions would the nurse teach the client? Select all that apply.
The nurse is ambulating a client for the first time after having abdominal surgery. What clinical manifestations would indicate to the nurse that the client may be experiencing orthostatic hypotension? Select all that apply.
The nurse who has been closely monitoring a child who has been exhibiting decorticate (flexor) posturing after sustaining severe head trauma notes that the child suddenly exhibits decerebrate (extensor) posturing. The nurse interprets that this change in the child’s posturing indicates what?
The nurse is performing an assessment on a female client who is suspected of having mittelschmerz. Which subjective finding supports the possibility of this condition?
The nurse assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup notes that the respiratory rate is 28 breaths/min. Based on this finding, which nursing action is appropriate?
The nurse, while caring for a hospitalized infant being monitored for hydrocephalus, notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which conclusion would the nurse draw?
During a health assessment, the client tells the nurse that she was diagnosed with endometriosis. Which explanation presented by the client demonstrates an understanding of the description of the condition
An adolescent is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment of scoliosis. Which assessments are most important in the immediate postoperative period when considering the client’s neurovascular status? Select all that apply.
A hepatitis B screen is performed on a postpartum client, and the results indicate the presence of antigens in the maternal blood. Which intervention would the nurse anticipate to be prescribed to protect the neonate? Select all that apply.
The nurse has just finished assisting the primary health care provider in placing a central intravenous (IV) line in a client with gastric cancer. Which is a priority intervention to assure the client’s safety?
A pregnant client reports that her last menstrual period (LMP) was February 9, 2022. Using Näegele’s rule, what will the nurse determine as the estimated date of birth?
The nurse is developing a plan of care for a client who suffered a pelvic fracture following a motor vehicle crash (MVC). Which interventions would be included in the nursing care plan to prevent skin breakdown? Select all that apply.
The nurse is measuring the fundal height on a client who is 36 weeks of gestation when the client reports feeling lightheaded. What finding would the nurse expect to note when assessing the client?
The nurse in the prenatal clinic is monitoring a client who is pregnant with twins. The nurse monitors the client closely for which priority complication that is associated with a twin pregnancy?
A clinic nurse is assessing a prenatal client who has been diagnosed with heart disease. The nurse carefully assesses the client’s vital signs, weight, and fluid and nutritional status to detect for complications caused by which pregnancy-related concern?
A 2-year-old toddler has just returned from surgery where a hip spica cast was applied. Which nursing action will best maintain the child’s skin integrity?
The nurse performs the Glasgow Coma Scale while assessing a client with a brainstem injury. Which additional interventions would the nurse be prepared to implement? Select all that apply.
A client with a bowel obstruction has had a nasointestinal (NI) tube in place for 24 hours. Which assessment finding indicates that the tube is properly located in the intestine?
A client diagnosed with myxedema reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse plans care knowing that these clinical manifestations are caused by a lack of production of which hormones? Select all that apply.
A client is admitted to the hospital with a suspected diagnosis of Graves’ disease. On assessment, which manifestation related to the client’s menstrual cycle would the nurse expect the client to report?
A client diagnosed with gestational hypertension has just been admitted and is in early active labor. Which assessment finding would the nurse most likely expect to note?
A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse would provide for the client?
The nurse is preparing to measure the fundal height of a client whose fetus is 28 weeks of gestation. In what position would the nurse place the client to perform the procedure?
The nurse is counseling the family of a terminally ill client about palliative care. The nurse identifies which goals as being those of palliative care? Select all that apply.
As part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location?
The nurse is caring for a client receiving bolus feedings via a nasogastric (NG) tube after surgery for stomach cancer. The nurse would place the client in which position to administer the feeding?
The nurse monitors a patient diagnosed with acute pancreatitis. Which assessment finding indicates that paralytic ileus has developed?
After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. When asked, how would the nurse describe this finding to the client?
A client has just been admitted to the emergency department with reports of chest pain. Serum cardiac enzyme levels are drawn, and the results indicate an elevated serum creatine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with what diagnosis?
The nurse is performing range-of-motion (ROM) exercises on a client when the client unexpectedly develops spastic muscle contractions. Which interventions would the nurse implement? Select all that apply.
The nurse plans care for a client diagnosed with end-stage renal disease (ESRD). Which assessment findings does the nurse expect to note documented in the client’s medical record? Select all that apply.
The nurse caring for a 5-year-old with a history of tetralogy of Fallot notes that the child has clubbed fingers. This finding is indicative of which associated condition?
The nurse admits a client who is in sickle cell crisis. The nurse would prepare for which intervention as a priority in the management of the client?
The nurse analyzed an electrocardiogram (ECG) strip (refer to figure) for a client demonstrating left-sided heart failure and interprets the ECG strip as which rhythm?
A client has been admitted with a diagnosis of acute glomerulonephritis. During history taking, the nurse would ask the client about a recent history of which event?
Which important parameter would the nurse assess daily for a client diagnosed with nephrotic syndrome?
A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?
A client is being admitted with a diagnosis of urolithiasis and ureteral colic. The nurse expects to note which finding on pain assessment?
The client with heart failure states the need to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding?