The nurse walks into a client's room and finds the

Question 1 of 9

The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first

A. Assess the client's airway. B. Call for help. C. Establish that the client is unresponsive. D. See if anyone saw the client fall.

Correct Answer: C

Rationale: Checking responsiveness is the first step in assessing the situation.

Question 2 of 9

During assessment, a healthcare provider is evaluating a client with chronic bronchitis. Which of the following percussion sounds should the healthcare provider expect?

A. Dullness B. Resonance C. Tympany D. Flatness

Correct Answer: B

Rationale: The correct answer is B: Resonance. When assessing a client with chronic bronchitis, the healthcare provider should expect to hear resonant percussion sounds. This is because chronic bronchitis is characterized by inflammation and excess mucus production in the bronchial tubes, leading to airway obstruction. Resonance indicates normal lung tissue and air-filled spaces. Dullness (A) may suggest consolidation or fluid in the lungs, which is not typically associated with chronic bronchitis. Tympany (C) is a drum-like sound that can be heard over air-filled structures like the stomach, not typically expected in a lung assessment. Flatness (D) is heard over solid structures like the liver and would not be expected in a lung assessment for chronic bronchitis.

Question 3 of 9

Your postoperative patient develops a cellulitis in her leg. Your nursing treatments would include

A. Keeping both her legs elevated as much as possible. B. Encouraging ambulation as much as possible to help with the blood flow. C. Application of ice four times a day for an hour each to reduce inflammation. D. Application of moisturizing lotion three times daily to keep the skin moist.

Correct Answer: A

Rationale: Elevation helps reduce swelling and improve circulation in cellulitis.

Question 4 of 9

A preoperative patient reveals that an uncle died during surgery because of a fever and cardiac arrest. Knowing the patient is at risk for malignant hyperthermia, the perioperative nurse alerts the surgical team. What is likely to happen next?

A. The surgery will have to be cancelled. B. Specific precautions can be taken to safely anesthetize the patient. C. Dantrolene (Dantrium) must be given to prevent hyperthermia during surgery. D. The patient should be placed on a cooling blanket during the surgical procedure.

Correct Answer: B

Rationale: With awareness of malignant hyperthermia risk, specific precautions ensure safe anesthesia administration.

Question 5 of 9

What nursing measure would be most helpful in obtaining Mr. Smith’s compliance with treatment?

A. Involve Mrs. Smith in the teaching sessions B. Teach Mr. Smith about his prescribed medications C. Ask the social worker to talk to Mr. Smith D. Refer the Smiths to the American Lung Association

Correct Answer: B

Rationale: Education empowers patients to understand and adhere to their treatment plans.

Question 6 of 9

An 88-year-old woman is brought to the health clinic for the first time by her 64-year-old daughter. During the initial comprehensive nursing assessment of the patient, what should the nurse do?

A. Ask the daughter whether the patient has any urgent needs or problems. B. Interview the patient and daughter together so that pertinent information can be confirmed. C. Obtain a health history using a functional health pattern and assess activities of daily living (ADLs) and mental status. D. Refer the patient for an interdisciplinary comprehensive geriatric assessment because at her age she will have multiple needs.

Correct Answer: C

Rationale: Assessing ADLs, mental status, and obtaining a thorough health history ensures comprehensive understanding of the patient's needs.

Question 7 of 9

What best evaluates Mrs. West’s situation with wound separation and purulent drainage?

A. This response is consistent with the inflammatory process B. Some drainage is to be expected from a surgical incision C. This response indicates a break in sterile technique has occurred D. This wound is healing by first intention

Correct Answer: A

Rationale: Inflammatory signs suggest infection, requiring further evaluation and treatment.

Question 8 of 9

What additional assessment should be made if there is no fluid in Mr. Jones’ chest tubes?

A. Turn Mr. Jones on his left side and observe for drainage B. Clamp the chest tubes and observe Mr. Jones’ breathing pattern C. Auscultate for equal breath sounds bilaterally D. Monitor vital signs closely for hypotension, tachycardia

Correct Answer: C

Rationale: Equal breath sounds indicate proper lung expansion and functioning.

Question 9 of 9

Which vitamin does a client lack if there is a problem with the absorption of calcium?

A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin D

Correct Answer: D

Rationale: Vitamin D is essential for calcium absorption in the intestines. A deficiency impairs this process.

The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first

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