ncompressible sounds. Which of the following Glasgow coma scale scores should the nurse assign the client? A. 2 B. 5 C. 10 D. 13 - CORRECT ANSWERS-B.
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A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility? A. Confusion B. Polyuria C. Blurred vision D. Diarrhea - CORRECT ANSWERS-A. Confusion
A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following should the nurse take first? A. Check the color of the client's skin B. Prepare the client's clothing C. Remove all the clients clothing D. Administer an opioid analgesic - CORRECT ANSWERS-A. Check the color of the client's skin
A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first? A. Administer IV therapy B.. Insert a large bore IV catheter C. Monitor urine output D. Obtain a blood specimen for type and crossmatch - CORRECT ANSWERS-B. Insert a large bore IV catheter A nurse in the intensive care unit is caring for a client who has the following ABG results: pH 7.30; HCO3 19 mEq/L, PaCO2 with the expected reference range A. respiratory alkalosis B. Respiratory acidosis C. Metabolic acidosis D. Metabolic alkalosis - CORRECT ANSWERS-C. Metabolic acidosis A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective? A. Elevation in blood pressure B. Adventitious breath sounds C. Weight loss of 1.8 kg (4lb) in the past 24 hr D. Respiratory rate of 24/min - CORRECT ANSWERS-C. Weight loss of 1.8 kg (4lb) in the past 24 hr A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax? A. Diminished breath sounds B. Distended neck veins C. Irregular heart rate D. Itching over the incision - CORRECT ANSWERS-A. Diminished breath sounds A nurse is assessing a client who has an arteriovenous (AV) fistula in the left forearm. Which of the following findings should the nurse identify as an indication of a complication at the vascular access site? A. Presence of palpable thrill B. 2+ left radial pulse C. Absence of bruit D. Dilated appearance of the AV site - CORRECT ANSWERS-C. Absence of bruit
A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect? A. Hyperproteinemia B. Cachexia C. Diplopia D. Hypermagnesemia - CORRECT ANSWERS-B. Cachexia A nurse is caring for a client in the ER following a myocardial infarction. Which of the following actions should the nurse anticipate if the client develops asystole? A. Administer atropine B. Defibrillate with 200 joules C. Start a continuous lidocaine infusion D. Begin CPR - CORRECT ANSWERS-D. Begin CPR
A nurse is caring for a client who develops third-degree heart block with a heart rate of 30/min. Which of the following actions should the nurse take? A. Instruct the client to perform the Valsalva Maneuver B. Prepare the client for temporary pacing C. Perform carotid sinus massage D. Administer digoxin by IV bolus - CORRECT ANSWERS-B. Prepare the client for temporary pacing A nurse is caring for a client who had a total hip arthroplasty. Which of the following action should the nurse take to prevent hip dislocation? A. Place two bed pillows between the legs when in bed B. Encourage the client to lean forward when attempting to stand C. Elevate the knees higher than the hips when sitting D. Remove the wedge device when turning - CORRECT ANSWERS-A. Place two bed pillows between the legs when in bed A nurse is caring for a client who has a sealed radiation implant which of the following actions should the nurse take? A. Limit family member visits to 30 min per day B. Give the dosimeter badge to the oncoming nurse at the end of the shift C. Apply second pair of gloves before touching the clients implant if it dislodges D. Remove soiled lines from the room after each change - CORRECT ANSWERS-A. Limit family member visits to 30 min per day A nurse is caring for a client who has a traumatic brain injury. The client who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first? A. Urinary output B. Motor responses C. Blood pressure D. Blood glucose - CORRECT ANSWERS-B. Motor responses A nurse is caring for a client who has atrial fibrillation. Which of the following should the nurse expect to administer? A. Dobutamine B. Lidocaine C. Atropine D. Amiodarone - CORRECT ANSWERS-D. Amiodarone
A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning. The nurse should recognize these assessment findings as indicating which of the following findings? A. Pleural effusion B. Increased cardiac output C. Fluid volume excess D. Aspiration - CORRECT ANSWERS-C. Fluid volume excess A nurse is caring for a client who has contusion of the brainstem and reports thirst. The client's urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of the following IV medications? A. Desmopressin B. Epinephrine C. Furosemide D. Nitroprusside - CORRECT ANSWERS-A. Desmopressin
A nurse is caring for a client who has hypertension and a new prescription for lisinopril. The nurse should consult with the provider about which of the following medications in the client's administration record? A. Potassium chloride B. Levothyroxine C. Acetaminophen D. Metformin - CORRECT ANSWERS-D. Metformin A nurse is caring for a client who has rheumatoid arthritis and reports increasing fatigue. The nurse should instruct the client to take which of the following actions to conserve energy? A. Avoid using large muscle groups B. Allow others to perform her self-care activities C. Determine priority activities to accomplish D. Limit iron intake - CORRECT ANSWERS-C. Determine priority activities to accomplish A nurse is caring for a client who has thrombocytopenia. Which of the following laboratory results should the nurse expect? A. Platelets 70,000/mm3 B. aPPT 40 seconds C. INR of 1.0 D. PT 11 seconds - CORRECT ANSWERS-A. Platelets 70,000/mm3 A nurse is caring for a client who has ulcerative colitis and was admitted to the medical surgical unit for management of diarrhea. Which of the following food items should the nurse select for the client's breakfast tray? A. Whole grain toast B. Poached egg C. Oatmeal D. Fresh peaches - CORRECT ANSWERS-B. Poached egg A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a prescription for opioid analgesia. Which of the following actions should the nurse implement to help facilitate the client's recovery? A. Provide analgesic medication prior to physical activity B. Inform the client to monitor for loose stools while taking opioid analgesia C. Withhold analgesic medication unless the client reports pain D. Administer naloxone if the client's respiratory rate is greater than 24/min - CORRECT ANSWERS-A. Provide analgesic medication prior to physical activity
A nurse is caring for a client who is 2 days postoperative following below the knee amputation and asks about the purpose of maintaining an elastic bandage around residual limb of the extremity. Which of the following is the appropriate response by the nurse? A. The elastic bandage will prevent a postoperative wound infection B. The elastic bandage will prevent excess edema C. The elastic bandage will keep you from seeing the surgical site D. The elastic bandage will keep the sutures from loosening - CORRECT ANSWERS-B. The elastic bandage will prevent excess edema
A nurse is caring for a client [Show Less]