The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?

• A.Palpate these pulses again in 15 minutes.
• B.Use a Doppler to determine presence and strength of these pulses.
• C.Document the finding that the pulses are not palpable.
• D.Call the physician and notify the physician of this finding.

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A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks' gestation. Based on the nurse's knowledge of the maternal physiological changes in pregnancy, which of these findings would be of concern?

• A.Complaints of dyspnea
• B.Edema of face and hands
• C.Pulse of 65 bpm at 8 weeks, 73 bpm at 36 weeks
• D.Hematocrit 39%

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A client has begun to exhibit signs of alcohol withdrawal. Her blood pressure has risen from 120/60 to
190/100, pulse is increased from 88 to 110 bpm, and she is irritable and agitated and has gross motor tremors of the hands. The nurse notifies the doctor. The nurse can anticipate that the doctor will order which of the following?

• A.An opiate such as propoxyphene napsylate (Darvocet)
• B.A benzodiazepine such as chlordiazepoxide (Librium)
• C.A tricyclic antidepressant such as amitriptyline (Elavil)
• D.A phenothiazine such as chlorpromazine (Thorazine)

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A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?

• A.D50W by IV push
• B.NPH insulin SC
• C.Regular insulin by IV infusion
• D.Sweetened grape juice by mouth

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A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?

• A.Pain in his legs when he walks
• B.Thirst, weight loss, and polyuria
• C.Drowsiness and lethargy after his activities
• D.Weight gain, edema in his lower extremities, and shortness of breath

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