1. A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first?
Assess orthostatic blood pressure
Explain the procedure for an upper gastrointestinal series.
Administer pain medication.
Test the client's emesis for blood.
2. A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting a NG tube into the client, which of the following findings should the nurse anticipate?
Frothy pink drainage
Dark amber drainage
Coffee-ground drainage
Greenish-yellow drainage
3. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
pulse and blood pressure findings
behavioral indicators and effect
scheduled treatments and client illness
a self-report pain rating scale
4. A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?
Apply the bag for 30 min at a time.
Reapply the bag 30 min after removing it.
Allow room for some air inside the bag.
Place the bag directly on the skin.
5. A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?
"It might help if I tried sleeping only on my back."
"I'll sleep better if I take a sleeping pill at night."
"I'll get a humidifier to run at my bedside at night."
"If I could lose about 50 pounds, I might stop having so many apneic episodes."
6. A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30 lb, and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving?
The client is 48 years old.
The client's husband died seven months ago.
The client has lost 30 lb.
The client is having difficulty sleeping.
7. A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?
"Eating yogurt can help decrease the amount of gas that I have."
"I should eliminate pasta from my diet so that I don't have as many loose stools."
"My largest meal of the day should be in the evening."
"Carbonated beverages can help control odor."
8. A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?
Stoma oozing red drainage
Shiny, moist stoma
Purplish-colored stoma
Rosebud-like stoma orifice
9. A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
BUN
Potassium
RBC count
WBC count
10. A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention?
"Does your skin condition keep you awake at night?"
"Have you had any changes in your diet?"
"How do you handle stress?"
"How does your skin condition make you feel?"