A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change?

A client who has multiple sclerosis and is experiencing progressive difficulty ambulating.

Explanation: The progressive nature of multiple sclerosis can lead to significant changes in the client’s ability to perform daily tasks, affecting their role at home or work.

A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?

Sedimentation rate

Explanation: An elevated sedimentation rate (ESR) is a common indicator of inflammation and can suggest an infection such as osteomyelitis in a client with a recent fracture.

A nurse is caring for a client who is postoperative. What condition is the client most likely experiencing, and what actions should the nurse take?

Hypovolemia

Initiate fluid challenge and insert a large-gauge IV.

Monitor blood pressure and urine output.

Explanation: The client’s symptoms indicate hypovolemia, and the nurse should administer fluids and monitor vital signs to assess the response.

A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include?

“You will need to stay still in the bed during each treatment session.”

Explanation: During brachytherapy, it is important to minimize movement to prevent dislodging the radioactive source.

A nurse is caring for a client who is receiving dialysis treatment. Which of the following interventions are indicated or not indicated?

Indicated: Place the client in Trendelenburg position, notify the provider immediately, administer a 0.9% sodium chloride IV bolus, apply oxygen at 2 L/min.

Not Indicated: Obtain blood glucose level, perform a 12-lead ECG.

Explanation: These interventions are prioritized for managing dialysis-related complications such as hypotension.

A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings?

Dysphagia

Explanation: Dysphagia (difficulty swallowing) is a critical concern in stroke patients as it can lead to aspiration and respiratory complications.

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place a pillow between the client’s legs.

Explanation: A pillow helps prevent hip dislocation by maintaining proper alignment of the hip joint.

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?

“Ginkgo biloba can cause an increased risk for bleeding.”

Explanation: Ginkgo biloba can increase the risk of bleeding, especially in clients taking anticoagulants or undergoing surgery.

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?

Demonstrate ways to deep breathe and cough.

Explanation: Teaching proper breathing techniques helps prevent postoperative respiratory complications.

A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?

Dyspnea

Explanation: Thoracentesis removes excess fluid from the pleural space, relieving pressure and improving breathing.

A nurse is assessing a client while suctioning the client’s tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia?

The client’s heart rate increases.

Explanation: Tachycardia is a sign of hypoxia and indicates that the client may not be receiving adequate oxygen.

A nurse in the emergency department is caring for a client. The client is experiencing manifestations of which condition?

Pancreatitis as evidenced by elevated amylase and lipase levels.

Explanation: Elevated levels of these enzymes are diagnostic markers for pancreatitis.

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse’s priority?

Temperature 38.9° C (102° F)

Explanation: A high temperature post-thyroidectomy can indicate infection or a thyroid storm, a life-threatening condition.

A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?

Initiate airborne precautions.

Explanation: These symptoms are indicative of tuberculosis, requiring immediate airborne isolation to prevent the spread of infection.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the client to splint the abdomen with a pillow for coughing.

Report urinary output to the provider.

Plan to ambulate the client as soon as possible.

Ask the client to rate their pain on a 0 to 10 pain scale.

Explanation: These actions help promote recovery and prevent complications post-surgery.

A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?

Ensure that the client has a patent IV.

Explanation: Having a patent IV allows for the quick administration of emergency medications in the event of a seizure.

A nurse is caring for a client experiencing manifestations of peritonitis. What diagnostic test should the nurse expect to confirm this condition?

X-ray results

Explanation: An abdominal X-ray can reveal air or fluid in the abdomen, which are indicators of peritonitis.

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

“I will monitor my blood pressure while taking this medication.”

Explanation: Epoetin alfa can increase blood pressure, so clients must regularly monitor it.

A nurse is caring for a client who has portal hypertension and is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs.

Explanation: Vital signs will help assess the severity of the bleeding and the client’s overall condition.

A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?

Hypoactive bowel sounds

Explanation: Hypokalemia can cause decreased gastrointestinal motility, leading to hypoactive bowel sounds.

A nurse is providing preoperative teaching for a client scheduled for a mastectomy. Which of the following statements should the nurse make?

“I will refer you to community resources that can provide support.”

Explanation: Support groups and community resources can help the client cope with the physical and emotional impacts of mastectomy.

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect?

Constipation

Explanation: Hypothyroidism slows metabolism, which can lead to constipation.