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42. A nurse is performing an integumentary assessment on a 6…

42. A nurse is performing an integumentary assessment on a 60-year-old patient with a history of prolonged sun exposure. The nurse is assessing for the presence of any abnormal lesions. Which of the following techniques demonstrates the correct method for inspecting and palpating the skin for lesions or abnormalities?

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20. A nurse is caring for a client receiving an IV of a hype…

20. A nurse is caring for a client receiving an IV of a hypertonic solution. Which assessment is a priority for the nurse to monitor while the client is receiving this infusion?

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37. A 45-year-old patient with a history of breast cancer an…

37. A 45-year-old patient with a history of breast cancer and an implanted infusaport for chemotherapy is scheduled for routine blood work. The nurse is preparing to draw blood from the infusaport. Which of the following actions should the nurse take to ensure the procedure is done safely?

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17. The nurse is caring for a client who is receiving isoton…

17. The nurse is caring for a client who is receiving isotonic intravenous (IV) fluids at an infusion rate of 125 mL/h. The nurse performs an assessment and notes a heart rate of 102 beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs. Which is the priority action for the nurse?

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28. A patient is admitted to the unit with chronic gastroint…

28. A patient is admitted to the unit with chronic gastrointestinal symptoms.  The nurse is reviewing the laboratory values and notes which of the following indicates the patient may be experiencing hypoxemia? 

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15. A nurse is assessing a client who is receiving total par…

15. A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse recognize as an early complication of this therapy?

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19. The nurse is assessing a client brought to the emergency…

19. The nurse is assessing a client brought to the emergency department for treatment for dehydration. The nurse assesses a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The client becomes dizzy when transferred from the wheelchair to a bed. The nurse notes cool, clammy skin. The patient’s symptoms correlate with which of the following? 

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31. When palpating a child’s cervical lymph nodes, the nurse…

31. When palpating a child’s cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm.  Which of the following best describes the reason for this finding? 

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38. A 60-year-old patient with congestive heart failure (CHF…

38. A 60-year-old patient with congestive heart failure (CHF) and a history of hypertension is admitted to the hospital with acute pulmonary edema. The healthcare provider orders an IV infusion of a hypertonic solution to manage electrolyte imbalances. The nurse is preparing to administer the infusion. What complication should the nurse be most concerned about for this patient, given their hypervolemic state?

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27. Which of the following postural abnormalities is charact…

27. Which of the following postural abnormalities is characterized by increased lumbar curvature and is often referred to as “swayback?”

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