A nurse is assessing for early signs of compartment syndrome for a client who has
a short-leg fiberglass cast. Which of the following findings should the
... [Show More] nurse
expect?
A. Capillary refill less than 2 seconds
B. Bounding distal pulses
C. Intense pain with movement
d. Erythema of the toes - C. Intense pain with movement
A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the
following manifestations indicates a haemolytic transfusion reaction?
A. Chills
B. Hypertension
C. Bradycardia
D. Back pain - A. Chills
A nurse is caring for a client who had a total hip arthroplasty. Which of the
following actions should the nurse take to prevent hip dislocation?
A. Remove the wedge device when turning
B. Place two bed pillows between the legs when in bed
C. Encourage the client to lean forward when attempting to stand
D. Elevate the knees higher than the hips when sitting - B. Place two bed pillows
between the legs when in bed
A nurse is assessing a client who is preoperative and reports an allergy to bananas.
The nurse should recognize that the client is at risk for an allergic cross-reactivity
to which of the following substances
A. Povidone-iodine
B. Adhesive tape
C. Latex
D. Anesthetics - C. Latex
A nurse is teaching a client about the use of an incentive spirometer. Which of the
following instructions should the nurse include in the teaching?
A. Place hands on the upper abdomen during inhalation.
B. Position the mouthpiece 2.5 cm (1 in) from the mouth
C. Exhale slowly through pursed lips
D. Hold breaths about 3 to 5 seconds before exhaling
- D. Hold breaths about 3 to 5 seconds before exhalingA nurse is caring for a client who arrives at the emergency department and reports
vomiting and diarrhea for the past 3 days. The client's serum potassium level is
2.8mEq/L. Which of the following interventions should the nurse implement first?
A. Check the clients hand grasps
B. Administer an IV potassium drip
C. Listen to the client's bowel sounds
D. Initiate cardiac monitoring for the clients - D. Initiate cardiac monitoring for the
clients
A nurse is preparing to administer peritoneal dialysis to a client. Which of the
following actions should the nurse take?
A. Chill the dialysate before administration
B. Hang the drainage bag below the client's abdomen
C. Place the client in high-Fowlers position
D. Use clean technique to access the catheter - B. Hang the drainage bag below the
client's abdomen
A nurse is preforming a cranial nerve assessment on a client following a head
injury. Which of the following findings should the nurse expect if the client has
impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
A. Inability to smell
B. loss of peripheral vision
C. Disequilibrium with movement
D. Deviation of the tongue from midline - C. Disequilibrium with movement
A nurse is planning care for a client who is one day postoperative Following an
open cholecystectomy. Which of the following interventions should the nurse
include in the plan of care?
A. Place pillows under the clients knees
B. Avoid use of anticoagulants
C. Discourage leg exercises while in bed
D. apply compression stockings to the lower extremities - D. apply compression
stockings to the lower extremities [Show Less]