Question 1
Care of the Adult Exam. The nurse is assessing a client admitted for a fracture of the left tibia, who has a splint on the left leg. The client reports numbness in the left foot. What priority action should the nurse perform?
- Send the client for a lower extremity ultrasound.
- Complete a neurovascular assessment of the left leg.
- Loosen and reposition the lower extremity splint.
- Elevate and apply ice to the left lower extremity.
Question 37
Which client should the nurse assess first after receiving the shift report?
- A client with heart failure who has 2+ pitting edema in the lower extremities
- A client with a history of deep vein thrombosis who reports sudden chest pain and dyspnea
- A client with hypertension whose blood pressure is 158/92 mmHg
- A client with end-stage renal disease who is waiting for scheduled dialysis
Question 38
A client is admitted with a diagnosis of acute pericarditis. Which assessment finding should the nurse expect?
- Chest pain that is relieved by leaning forward
- A systolic murmur heard best at the apex
- Pitting edema in the bilateral lower extremities
- Bradycardia with a heart rate of 52 beats per minute
Question 39
The nurse is providing education to a client with Raynaud’s phenomenon. Which instruction is most important to include?
- “Protect your hands and feet from cold temperatures.”
- “Apply ice packs to your fingers when they turn white.”
- “Avoid all forms of physical exercise.”
- “Soak your hands in hot water for 30 minutes daily.”
Question 40
Which laboratory result requires immediate notification of the healthcare provider for a client receiving a continuous heparin infusion?
- Prothrombin time (PT) of 12 seconds
- International Normalized Ratio (INR) of 1.1
- Platelet count of 90,000/mm³
- Activated partial thromboplastin time (aPTT) of 65 seconds
Question 41
A client with chronic venous insufficiency is being discharged. Which self-care measure should the nurse emphasize?
- “Wear compression stockings as prescribed.”
- “Sit with your legs in a dependent position for long periods.”
- “Limit your fluid intake to 1 liter per day.”
- “Avoid walking to prevent further leg damage.”
Question 42
The nurse is assessing a client for the Presence of Homan’s sign. Which action should the nurse perform?
- Ask the client to stand and march in place
- Dorsiflex the client’s foot and ask about calf pain
- Palpate the popliteal pulse for strength
- Percuss the client’s tibia for tenderness
Question 43
Which medication is typically prescribed for a client experiencing an acute episode of angina pectoris?
- Furosemide
- Nitroglycerin
- Metoprolol
- Lisinopril
Question 44
A client is diagnosed with Buerger’s disease (thromboangiitis obliterans). Which lifestyle modification is essential for the client to follow?
- Complete cessation of tobacco use
- Adoption of a high-protein diet
- Reducing daily physical activity
- Taking daily vitamin C supplements
Question 45
Care of the Adult Exam. What is the most serious complication of an abdominal aortic aneurysm (AAA)?
- Infection of the vessel wall
- Rupture of the aneurysm
- Development of deep vein thrombosis
- Gradual narrowing of the vessel
Question 46
The nurse is caring for a client with infective endocarditis. Which assessment finding is a classic sign of this condition?
- Pleuritic chest pain
- Splinter hemorrhages in the nail beds
- Absent pedal pulses
- Symmetrical facial drooping
Question 47
A nurse is preparing to administer sublingual nitroglycerin. What should the nurse tell the client to expect?
- A tingling or burning sensation under the tongue
- Immediate drowsiness and sedation
- Sudden increase in appetite
- Temporary loss of taste
Question 48
Which food choice is most appropriate for a client on a low-sodium diet?
- Cured ham
- Pickled beets
- Fresh baked chicken breast
- Low-fat cottage cheese
Question 49
The nurse is monitoring a client’s EKG strip and notes a saw-tooth pattern. Which rhythm is the client likely experiencing?
- Ventricular fibrillation
- Sinus tachycardia
- Atrial flutter
- First-degree AV block
Question 50
Which sign or symptom is indicative of a developing pulmonary embolism in a postoperative client?
- Sudden onset of shortness of breath and chest pain
- Productive cough with green sputum
- Gradual increase in blood pressure
- Numbness in the fingers and toes
