Which of the following client situations would require the most intens

Adult Health Med Surg NCLEX Test Bank

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Question 1 of 5.

Which of the following client situations would require the most intensive nursing interventions for immobility?

A. A 38-year-old woman receiving internal radiation therapy for cervical cancer.

B. A 7-year-old boy with leukemia hospitalized for induction of high-dose chemotherapy.

C. A 75-year-old man with metastatic prostate cancer hospitalized for a pathologic fracture of the femur.

D. A 6-month-old undergoing surgery for placement of a central venous catheter.

Explanation: A 75-year-old man with a pathologic femur fracture requires the most intensive nursing interventions for immobility due to pain, risk of further injury, and need for mobility aids and rehabilitation.

Question 2 of 5.

The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following?

A. Atrial fibrillation.

B. Ventricular tachycardia.

C. Premature ventricular contractions (PVCs).

D. Third-degree heart block.

Explanation: Without the ECG strip, the rhythm cannot be identified. This question is incomplete in the provided document.

Question 3 of 5.

After the administration of t-PA, the assessment priority is to:

A. Monitor the client for chest pain.

B. Monitor for fever.

C. Monitor the 12-lead electrocardiogram (ECG) every 4 hours.

D. Monitor breath sounds.

Explanation: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.

Question 4 of 5.

A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that:

A. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect.

B. Nitroglycerin should be avoided if the client is experiencing this serious side effect.

C. Taking the nitroglycerin with a few glasses of water will reduce the problem.

D. The client should lie in a supine position to alleviate the headache.

Explanation: Headache is a common side effect of nitroglycerin due to vasodilation. Acetaminophen or ibuprofen can safely relieve it without discontinuing the medication.

Question 5 of 5.

A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?

A. A low, grade 1 intensity mitral regurgitation murmur.

B. SpO2 is 94% on 2 liters of oxygen via nasal cannula.

C. The client has become more somnolent.

D. Urine output has decreased from 60 mL/hour to 40 mL over the last hour.

Explanation: Increased somnolence may indicate neurological complications (e.g., stroke) post-valvuloplasty, requiring immediate action. Other findings are less urgent.