A nurse is reinforcing teaching with a client who reports right shoulder pain
following a laparoscopic cholecystectomy. Which of the following
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should the nurse make?
1) "The pain results from lying in one position too long during surgery."
2) "The pain occurs as a residual pain from cholecystitis."
3) "The pain will dissipate if you ambulate frequently."
4) "The pain is caused from the nitrous dioxide injected into the
abdomen."
A nurse is checking the suction control chamber of a client's chest tube and notes
that there is nobubbling in the suction control chamber. Which of the following
actions should the nurse take?
1) Notify the provider.
Answer Rationale:
The nurse should check for kinks and take other measures before notifying the
provider.
2) Verify that the suction regulator is on.
3) Continue to monitor the client because this is an expected finding.
4) Milk the chest tube to dislodge any clots in the tubing that may be
occluding it.
A nurse is assisting with the care of a client immediately following a lumbar
puncture. Which of the following actions should the nurse take? (Select all that
apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client.
A nurse is assisting with the care of a client who is postoperative following
surgical repair of a fracturedmandible. The client’s jaw is wired shut to repair
and stabilize the fracture. The nurse should recognizewhich of the following
is the priority action?
1) Relieve the client's pain.
2) Check the client’s pressure points for redness.
3) Provide oral hygiene.
4) Prevent aspiration.
A nurse is collecting data from a client who has scleroderma. Which of the
following findings should the nurse expect?
1) A dry raised rash
2) Excessive salivation
3) Periorbital edema
4) Hardened skin
A nurse is caring for an older adult client who has dysphagia and left-sided
weakness following a stroke. Which of the following actions should the
nurse take?
1) Instruct the client to tilt her head back when she swallows.
2) Place food on the left side of the client's mouth.
3) Add thickener to fluids.
4) Serve food at room temperature.
A nurse is caring for a client who has partial-thickness and full-thickness
burns of his head, neck, and chest. The nurse should recognize which of the
following is the priority risk to the client?
1) Airway obstruction
2) Infection
3) Fluid imbalance
4) Contractures
A nurse is reinforcing teaching with a client who is newly diagnosed with
myasthenia gravis and is to start taking neostigmine. Which of the following
instructions should the nurse include in the teaching?
1) Take the medication 45 minutes before eating.
2) Expect diaphoresis as a side effect of the neostigmine.
3) If a medication dose is missed, wait until the next
scheduled dose to take the medication.
4) Treat nasal rhinitis with an over-the-counter antihistamine.
A nurse is caring for a client who is 12 hours postoperative following a
transurethral resection of the prostate (TURP) and has a 3-way urinary
catheter with continuous irrigation. The nurse notes there has not been any
urinary output in the last hour. Which of the following actions should the
nurse perform first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client
expresses fear about the procedure and asks the nurse if the biopsy will
hurt. Which of the following responses should the nurse make?
1) "You must be very worried about what the biopsy will show."
2) "You'll be asleep for the whole biopsy procedure and
won't be aware of what’s happening."
3) "Your provider scheduled this, so she will want to know you
still have questions about the procedure."
4) "The biopsy can be uncomfortable, but we will try to
keep you as comfortable as possible."
A nurse is assisting with planning care for a client who is recovering from a
left-hemispheric stroke. Which of the following interventions should the
nurse include in the plan?
1) Control impulsive behavior.
2) Compensate for left visual field deficits.
3) Re-establish communication.
4) Improve left-side motor function.
A nurse is assisting with the care of a client who has diabetes insipidus. The
nurse should monitor the client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
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